Basic Information
| Provider Information | |||||||||
| NPI: | 1790330355 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | TSEVDOS | ||||||||
| FirstName: | CODY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 576 BROADHOLLOW ROAD | ||||||||
| Address2: | SUITE PRO EX | ||||||||
| City: | MELVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11747 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6313595859 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1150 HALL OF FAME AVE STE 3 | ||||||||
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| City: | SPRINGFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 011052532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4132418900 | ||||||||
| FaxNumber: | 4132418901 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2019 | ||||||||
| LastUpdateDate: | 08/09/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 24336 | MA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.