MEDICARE: MR. TRAVIS R COOPER LPTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant	PTA1442	AL

General Provider Information

NPI Number	:	1073581054
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. TRAVIS R COOPER LPTA

Provider Business Mailing Address
First Line	:	2125 EXECUTIVE PARK DR
Second Line	:
City	:	OPELIKA
State	:	AL
Zip	:	36801-6041
Country	:	US
Telephone Number	:	334-741-4041
Fax Number	:	334-741-0065

Provider Business Practice Location Address
First Line	:	2125 EXECUTIVE PARK DR
Second Line	:
City	:	OPELIKA
State	:	AL
Zip	:	36801-6041
Country	:	US
Telephone Number	:	334-741-4041
Fax Number	:	334-741-0065

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/08/2006
Last Update Date	:	06/28/2019

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