Provider Demographics
NPI:1265296271
Name:MCCORD, SIDEA (CRANIAL PROTHESIS)
Entity type:Individual
Prefix:
First Name:SIDEA
Middle Name:
Last Name:MCCORD
Suffix:
Gender:F
Credentials:CRANIAL PROTHESIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11806 WHITE ASH DR
Mailing Address - Street 2:
Mailing Address - City:NEW PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34654-1938
Mailing Address - Country:US
Mailing Address - Phone:678-815-3738
Mailing Address - Fax:
Practice Address - Street 1:11806 WHITE ASH DR
Practice Address - Street 2:
Practice Address - City:NEW PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34654-1938
Practice Address - Country:US
Practice Address - Phone:678-815-3738
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-09
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACO129097224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetistGroup - Single Specialty