Provider Demographics
NPI:1669088142
Name:NEWELL, CODY JOHN (PTA)
Entity type:Individual
Prefix:
First Name:CODY
Middle Name:JOHN
Last Name:NEWELL
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 S MELROSE DR APT 172
Mailing Address - Street 2:
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92081-8777
Mailing Address - Country:US
Mailing Address - Phone:712-898-3273
Mailing Address - Fax:
Practice Address - Street 1:247 E BOBIER DR
Practice Address - Street 2:
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92084-3026
Practice Address - Country:US
Practice Address - Phone:760-945-3033
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-19
Last Update Date:2020-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA50718225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty