Provider Demographics
NPI:1497365266
Name:MCCORD, CHRISTIAN (RPSGT)
Entity Type:Individual
Prefix:
First Name:CHRISTIAN
Middle Name:
Last Name:MCCORD
Suffix:
Gender:M
Credentials:RPSGT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12586 W DEEP CANYON DR
Mailing Address - Street 2:
Mailing Address - City:STAR
Mailing Address - State:ID
Mailing Address - Zip Code:83669-5066
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3067 E COPPER POINT DR
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-1740
Practice Address - Country:US
Practice Address - Phone:208-287-1733
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-05
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPSG-180225500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225500000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/Technologist