Provider Demographics
NPI:1083166847
Name:CARLSON, CODY GENE
Entity Type:Individual
Prefix:
First Name:CODY
Middle Name:GENE
Last Name:CARLSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10500 COUNTY ROAD 601
Mailing Address - Street 2:
Mailing Address - City:CHAMPION
Mailing Address - State:MI
Mailing Address - Zip Code:49814-9467
Mailing Address - Country:US
Mailing Address - Phone:906-362-7411
Mailing Address - Fax:
Practice Address - Street 1:10500 COUNTY ROAD 601
Practice Address - Street 2:
Practice Address - City:CHAMPION
Practice Address - State:MI
Practice Address - Zip Code:49814-9467
Practice Address - Country:US
Practice Address - Phone:906-362-7411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-27
Last Update Date:2016-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer