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General NPI Number Information
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NPI Number | 1235744913
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Entity Type | Individual
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Provider Name | CODY DEARDORFF MAT, LAT, ATC
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Gender | Male
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Dates
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Enumeration Date | 09/10/2020
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Last Update Date | 09/10/2020
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Provider Practice Location Address
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Address Line | 3211 47TH ST
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City | LUBBOCK
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State | TX
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Zip | 79413-4112
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Country | US
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Telephone | 806-219-2042
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Fax | 806-766-0705
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Provider Business Mailing Address
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Address Line | 13407 INDIANA AVE APT 2108
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City | LUBBOCK
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State | TX
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Zip | 79423-1869
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Country | US
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Telephone | 806-787-7828
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | AT7951
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License Number State | TX
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