Provider Demographics
NPI:1023310752
Name:MRBRIDE, CODY
Entity type:Individual
Prefix:
First Name:CODY
Middle Name:
Last Name:MRBRIDE
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 1:14404 SHEEPROCK DR
Mailing Address - Street 2:
Mailing Address - City:HERRIMAN
Mailing Address - State:UT
Mailing Address - Zip Code:84096-3455
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7601 S REDWOOD RD.
Practice Address - Street 2:SUITE E
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84084
Practice Address - Country:US
Practice Address - Phone:801-776-8670
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-01
Last Update Date:2010-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program