Healthcare Provider Details

I. General information

NPI: 1700792819
Provider Name (Legal Business Name): KENNETH LADRAYN COOPER JR. LVN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/19/2026
Last Update Date: 08/19/2026
Certification Date: 08/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26001 REDLANDS BLVD
REDLANDS CA
92373-7762
US

IV. Provider business mailing address

11824 CONFLUENCE DR
JURUPA VALLEY CA
91752-2785
US

V. Phone/Fax

Practice location:
  • Phone: 909-825-7084
  • Fax:
Mailing address:
  • Phone: 909-800-4321
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License NumberC1594087
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: