Healthcare Provider Details

I. General information

NPI: 1821341447
Provider Name (Legal Business Name): CODY LEE WALLS ATC, LAT, EMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/19/2012
Last Update Date: 10/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4001 SUMMERHILL RD
TEXARKANA TX
75503-2764
US

IV. Provider business mailing address

4001 SUMMERHILL RD
TEXARKANA TX
75503-2764
US

V. Phone/Fax

Practice location:
  • Phone: 903-794-3891
  • Fax:
Mailing address:
  • Phone: 903-794-3891
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code146N00000X
TaxonomyBasic Emergency Medical Technician
License Number168141
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code146N00000X
TaxonomyBasic Emergency Medical Technician
License Number22756
License Number StateAR
# 3
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number1634643
License Number StateTX
# 4
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT4598
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: