=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801130794
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRIAN DAVID COOPER CMT/LMT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/16/2012
-----------------------------------------------------
Last Update Date | 07/10/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7450 HERITAGE VILLAGE PLZ SUITE 201
-----------------------------------------------------
City | GAINESVILLE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 20155-3090
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-800-5194
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9272 CALADIUM DR
-----------------------------------------------------
City | MANASSAS
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 20110-6083
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-800-5194
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 172M00000X
-----------------------------------------------------
Taxonomy Name | Mechanotherapist
-----------------------------------------------------
License Number | 0019009629
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 172M00000X
-----------------------------------------------------
Taxonomy Name | Mechanotherapist
-----------------------------------------------------
License Number | MT1634
-----------------------------------------------------
License Number State | DC
-----------------------------------------------------