Healthcare Provider Details

I. General information

NPI: 1780322834
Provider Name (Legal Business Name): GRACE COOPER RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2022
Last Update Date: 05/26/2022
Certification Date: 05/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 WATERCOVE RD
MIDLOTHIAN VA
23112-3982
US

IV. Provider business mailing address

4900 COX RD STE 155
GLEN ALLEN VA
23060-6507
US

V. Phone/Fax

Practice location:
  • Phone: 804-744-0200
  • Fax: 804-744-8417
Mailing address:
  • Phone: 804-726-8571
  • Fax: 804-726-8574

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: