Healthcare Provider Details

I. General information

NPI: 1134822125
Provider Name (Legal Business Name): MATTHEW COOPER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2023
Last Update Date: 03/27/2023
Certification Date: 03/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6627 W BROAD ST
RICHMOND VA
23230-1732
US

IV. Provider business mailing address

6201 WINNEPEG DR
BURKE VA
22015-3849
US

V. Phone/Fax

Practice location:
  • Phone: 804-764-1000
  • Fax:
Mailing address:
  • Phone: 703-965-7749
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: