Provider Demographics
NPI:1104390996
Name:KIDD, COY DANIEL
Entity Type:Individual
Prefix:
First Name:COY
Middle Name:DANIEL
Last Name:KIDD
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 1:1328 PISTOL LN
Mailing Address - Street 2:
Mailing Address - City:ONEIDA
Mailing Address - State:TN
Mailing Address - Zip Code:37841-6900
Mailing Address - Country:US
Mailing Address - Phone:423-215-8123
Mailing Address - Fax:
Practice Address - Street 1:55 W LAKE RD
Practice Address - Street 2:
Practice Address - City:PLEASANT HILL
Practice Address - State:TN
Practice Address - Zip Code:38578-3002
Practice Address - Country:US
Practice Address - Phone:931-277-3518
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-15
Last Update Date:2019-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN6840225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant