Healthcare Provider Details

I. General information

NPI: 1790771160
Provider Name (Legal Business Name): TERESA T COOPERRIDER O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2005
Last Update Date: 03/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

637 N UNION ST
LOUDONVILLE OH
44842-1074
US

IV. Provider business mailing address

637 N UNION ST
LOUDONVILLE OH
44842-1074
US

V. Phone/Fax

Practice location:
  • Phone: 419-994-4287
  • Fax: 419-994-2612
Mailing address:
  • Phone: 419-994-4287
  • Fax: 419-994-2612

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4055/T215
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: