Provider Demographics
NPI:1679257398
Name:MACKENZIE, CODY (ABOC)
Entity Type:Individual
Prefix:
First Name:CODY
Middle Name:
Last Name:MACKENZIE
Suffix:
Gender:M
Credentials:ABOC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:506 7TH ST W
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55102-3049
Mailing Address - Country:US
Mailing Address - Phone:651-333-4420
Mailing Address - Fax:
Practice Address - Street 1:506 7TH ST W
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-3049
Practice Address - Country:US
Practice Address - Phone:651-333-4420
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-13
Last Update Date:2023-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN237912156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician