Healthcare Provider Details

I. General information

NPI: 1639687155
Provider Name (Legal Business Name): CODY ALLEN WATERS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/18/2018
Last Update Date: 01/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1539 COUNTRY CLUB RD
FAIRMONT WV
26554-1306
US

IV. Provider business mailing address

837 MONONGALIA AVE
MORGANTOWN WV
26505-5732
US

V. Phone/Fax

Practice location:
  • Phone: 304-366-9100
  • Fax:
Mailing address:
  • Phone: 724-713-8106
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number003879
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: