Provider Demographics
NPI:1134729916
Name:DE LA MATER, CODY JAMES (DPT)
Entity type:Individual
Prefix:DR
First Name:CODY
Middle Name:JAMES
Last Name:DE LA MATER
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 BIRCH CT
Mailing Address - Street 2:
Mailing Address - City:RIFLE
Mailing Address - State:CO
Mailing Address - Zip Code:81650-2955
Mailing Address - Country:US
Mailing Address - Phone:714-472-8750
Mailing Address - Fax:
Practice Address - Street 1:406 HYLAND PARK DR STE F
Practice Address - Street 2:
Practice Address - City:GLENWOOD SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:81601-4270
Practice Address - Country:US
Practice Address - Phone:970-945-0506
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-29
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPTL.0017265261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy