Healthcare Provider Details

I. General information

NPI: 1073581054
Provider Name (Legal Business Name): TRAVIS R COOPER LPTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/08/2006
Last Update Date: 06/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2125 EXECUTIVE PARK DR
OPELIKA AL
36801-6041
US

IV. Provider business mailing address

2125 EXECUTIVE PARK DR
OPELIKA AL
36801-6041
US

V. Phone/Fax

Practice location:
  • Phone: 334-741-4041
  • Fax: 334-741-0065
Mailing address:
  • Phone: 334-741-4041
  • Fax: 334-741-0065

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA1442
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: