Basic Information
| Provider Information | |||||||||
| NPI: | 1851900237 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KILLGORE | ||||||||
| FirstName: | CODY | ||||||||
| MiddleName: | MITCHELL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | OTD, OTR/L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 555 N ARLINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | RENO | ||||||||
| State: | NV | ||||||||
| PostalCode: | 895034723 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7757863040 | ||||||||
| FaxNumber: | 7757861887 | ||||||||
| Practice Location | |||||||||
| Address1: | 555 N ARLINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | RENO | ||||||||
| State: | NV | ||||||||
| PostalCode: | 895034723 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7757863040 | ||||||||
| FaxNumber: | 7757866942 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2020 | ||||||||
| LastUpdateDate: | 04/29/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 2572 | NV | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 14931948 | 01 | CAQH | OTHER | 250009343 | 05 | NV | MEDICAID |