Healthcare Provider Details

I. General information

NPI: 1497006290
Provider Name (Legal Business Name): MARLA JEAN COOPER LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2012
Last Update Date: 09/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3961 E LOHMAN AVE STE 34
LAS CRUCES NM
88011-8269
US

IV. Provider business mailing address

1605 S TELSHOR BLVD #B
LAS CRUCES NM
88011-4861
US

V. Phone/Fax

Practice location:
  • Phone: 575-525-9960
  • Fax:
Mailing address:
  • Phone: 575-642-1292
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172M00000X
TaxonomyMechanotherapist
License Number5230
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: