Provider Demographics
NPI:1760843254
Name:BLACKFORD, CODY (ATC, LAT, CSCS)
Entity Type:Individual
Prefix:
First Name:CODY
Middle Name:
Last Name:BLACKFORD
Suffix:
Gender:M
Credentials:ATC, LAT, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1734 HALEY GLENN LN
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37920-9602
Mailing Address - Country:US
Mailing Address - Phone:865-271-8530
Mailing Address - Fax:
Practice Address - Street 1:1422 OLD WEISGARBER RD
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37909-1293
Practice Address - Country:US
Practice Address - Phone:865-680-7965
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-11
Last Update Date:2016-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN18802255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer