Provider Demographics
NPI:1821341447
Name:WALLS, CODY LEE (ATC, LAT, EMT)
Entity Type:Individual
Prefix:MR
First Name:CODY
Middle Name:LEE
Last Name:WALLS
Suffix:
Gender:M
Credentials:ATC, LAT, EMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4001 SUMMERHILL RD
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-2764
Mailing Address - Country:US
Mailing Address - Phone:903-794-3891
Mailing Address - Fax:
Practice Address - Street 1:4001 SUMMERHILL RD
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-2764
Practice Address - Country:US
Practice Address - Phone:903-794-3891
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-19
Last Update Date:2012-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX168141146N00000X
AR22756146N00000X
TX1634643174H00000X
TXAT45982255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic
No174H00000XOther Service ProvidersHealth Educator