Provider Demographics
NPI:1083113633
Name:CHURCH, CODY LEE (LAT, ATC)
Entity Type:Individual
Prefix:MR
First Name:CODY
Middle Name:LEE
Last Name:CHURCH
Suffix:
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4600 BIG TREE WAY APT 5V
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27409-2784
Mailing Address - Country:US
Mailing Address - Phone:336-905-5447
Mailing Address - Fax:
Practice Address - Street 1:5800 W FRIENDLY AVE
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27410-4108
Practice Address - Country:US
Practice Address - Phone:336-316-2513
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-09
Last Update Date:2018-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLAT-29832255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer