Basic Information
| Provider Information | |||||||||
| NPI: | 1669088142 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NEWELL | ||||||||
| FirstName: | CODY | ||||||||
| MiddleName: | JOHN | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2000 S MELROSE DR APT 172 | ||||||||
| Address2: | |||||||||
| City: | VISTA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920818777 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7128983273 | ||||||||
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| Practice Location | |||||||||
| Address1: | 247 E BOBIER DR | ||||||||
| Address2: | |||||||||
| City: | VISTA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920843026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7609453033 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/19/2020 | ||||||||
| LastUpdateDate: | 09/19/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 50718 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.