Healthcare Provider Details

I. General information

NPI: 1851177158
Provider Name (Legal Business Name): CODY-RYAN LEWIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/04/2023
Last Update Date: 09/04/2023
Certification Date: 09/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

323 EAST 5770 SOUTH
MURRAY UT
84107
US

IV. Provider business mailing address

323 EAST 5770 SOUTH
MURRAY UT
84107
US

V. Phone/Fax

Practice location:
  • Phone: 801-301-8004
  • Fax:
Mailing address:
  • Phone: 801-301-8004
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1744R1102X
TaxonomyResearch Study Specialist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number2545005702
License Number StateZZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: