Healthcare Provider Details

I. General information

NPI: 1770023483
Provider Name (Legal Business Name): ANNA C COPELAND RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/28/2017
Last Update Date: 02/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 OHIO ST
MEDINA NY
14103-1063
US

IV. Provider business mailing address

14789 STATE ROUTE 31
ALBION NY
14411-9709
US

V. Phone/Fax

Practice location:
  • Phone: 585-798-2000
  • Fax:
Mailing address:
  • Phone: 585-589-2273
  • Fax: 585-589-1876

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number008915-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: