Provider Demographics
NPI:1710456348
Name:SUDER, CODY
Entity Type:Individual
Prefix:
First Name:CODY
Middle Name:
Last Name:SUDER
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 1:100 WESTVIEW PARK PL
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901-3074
Mailing Address - Country:US
Mailing Address - Phone:406-393-2474
Mailing Address - Fax:406-393-2475
Practice Address - Street 1:100 WESTVIEW PARK PL
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-3074
Practice Address - Country:US
Practice Address - Phone:406-393-2474
Practice Address - Fax:406-393-2475
Is Sole Proprietor?:No
Enumeration Date:2018-11-13
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-6002225100000X
MT24541225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist