Provider Demographics
NPI:1245368166
Name:ROGERS, CODY FARREL (PT, MBA)
Entity type:Individual
Prefix:
First Name:CODY
Middle Name:FARREL
Last Name:ROGERS
Suffix:
Gender:M
Credentials:PT, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 BEAVER LAKE RD
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MS
Mailing Address - Zip Code:39443-7890
Mailing Address - Country:US
Mailing Address - Phone:601-729-2232
Mailing Address - Fax:
Practice Address - Street 1:23 MASON ST
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MS
Practice Address - Zip Code:39440-4437
Practice Address - Country:US
Practice Address - Phone:601-399-0534
Practice Address - Fax:601-425-7585
Is Sole Proprietor?:No
Enumeration Date:2007-03-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT3187225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist