Healthcare Provider Details

I. General information

NPI: 1457022410
Provider Name (Legal Business Name): COOPER DALE GRIFFITH PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2021
Last Update Date: 07/10/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

805 FRONTAGE RD
KENAI AK
99611-9104
US

IV. Provider business mailing address

PO BOX 2949
SOLDOTNA AK
99669-2949
US

V. Phone/Fax

Practice location:
  • Phone: 907-262-3119
  • Fax:
Mailing address:
  • Phone: 907-262-3119
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number205555
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: