Provider Demographics
NPI:1083229736
Name:GIVENS, CODY STORM
Entity Type:Individual
Prefix:
First Name:CODY
Middle Name:STORM
Last Name:GIVENS
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 1:1108 NEVILLE ST
Mailing Address - Street 2:
Mailing Address - City:FOLLANSBEE
Mailing Address - State:WV
Mailing Address - Zip Code:26037-1460
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:87 SWIERKOS DR
Practice Address - Street 2:
Practice Address - City:MOUNDSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26041-4209
Practice Address - Country:US
Practice Address - Phone:304-843-2306
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-10
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1356607394Medicaid
WV1821206228Medicaid
WV1255523494Medicaid