Provider Demographics
NPI:1568848943
Name:CHILDRESS, CODY (DC)
Entity Type:Individual
Prefix:DR
First Name:CODY
Middle Name:
Last Name:CHILDRESS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4317 E GENESEE ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:DE WITT
Mailing Address - State:NY
Mailing Address - Zip Code:13214-2114
Mailing Address - Country:US
Mailing Address - Phone:315-449-4465
Mailing Address - Fax:
Practice Address - Street 1:4317 E GENESEE ST
Practice Address - Street 2:SUITE 101
Practice Address - City:DE WITT
Practice Address - State:NY
Practice Address - Zip Code:13214-2114
Practice Address - Country:US
Practice Address - Phone:315-449-4465
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-07
Last Update Date:2015-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY70-012698111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor