Provider Demographics
NPI:1629728118
Name:MACH, CODY ALAN
Entity Type:Individual
Prefix:
First Name:CODY
Middle Name:ALAN
Last Name:MACH
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 1:2929 FLOYD AVE APT 368
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-8766
Mailing Address - Country:US
Mailing Address - Phone:507-330-0679
Mailing Address - Fax:
Practice Address - Street 1:2813 COFFEE RD
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-1755
Practice Address - Country:US
Practice Address - Phone:209-632-8888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-27
Last Update Date:2022-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20172225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist