Provider Demographics
NPI:1386182038
Name:WALLACE, CODY
Entity Type:Individual
Prefix:
First Name:CODY
Middle Name:
Last Name:WALLACE
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 1:12N854 MEADOWLARK DR
Mailing Address - Street 2:
Mailing Address - City:HAMPSHIRE
Mailing Address - State:IL
Mailing Address - Zip Code:60140-8919
Mailing Address - Country:US
Mailing Address - Phone:847-652-6743
Mailing Address - Fax:
Practice Address - Street 1:12N854 MEADOWLARK DR
Practice Address - Street 2:
Practice Address - City:HAMPSHIRE
Practice Address - State:IL
Practice Address - Zip Code:60140-8919
Practice Address - Country:US
Practice Address - Phone:847-652-6743
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-02
Last Update Date:2017-02-02
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