Healthcare Provider Details

I. General information

NPI: 1104358332
Provider Name (Legal Business Name): DENISE COOPER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2017
Last Update Date: 03/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7500 CENTRAL AVE SUITE 203
PHILADELPHIA PA
19111-2430
US

IV. Provider business mailing address

7500 CENTRAL AVE SUITE 203
PHILADELPHIA PA
19111-2430
US

V. Phone/Fax

Practice location:
  • Phone: 215-289-4434
  • Fax: 215-289-7442
Mailing address:
  • Phone: 215-289-4434
  • Fax: 215-289-7442

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: