Healthcare Provider Details

I. General information

NPI: 1437060332
Provider Name (Legal Business Name): MR. GARY COOPER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/17/2026
Last Update Date: 09/17/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

882 FOX ST NW
ATLANTA GA
30318-8464
US

IV. Provider business mailing address

882 FOX ST NW
ATLANTA GA
30318-8464
US

V. Phone/Fax

Practice location:
  • Phone: 678-308-3041
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT015589
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: