Provider Demographics
NPI:1053809848
Name:MCALISTER, KODI (LAT, ATC)
Entity type:Individual
Prefix:
First Name:KODI
Middle Name:
Last Name:MCALISTER
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12792 N BRANCH RD
Mailing Address - Street 2:
Mailing Address - City:PATRIOT
Mailing Address - State:IN
Mailing Address - Zip Code:47038-9453
Mailing Address - Country:US
Mailing Address - Phone:812-569-9667
Mailing Address - Fax:
Practice Address - Street 1:1020 W MAIN ST
Practice Address - Street 2:
Practice Address - City:VEVAY
Practice Address - State:IN
Practice Address - Zip Code:47043-8497
Practice Address - Country:US
Practice Address - Phone:812-427-2626
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-26
Last Update Date:2018-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0028472255A2300X
IN36001334A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer