MEDICARE: DRS. COOPER & BANNINGER, LLC.

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	152W00000X	Optometrist	1296	KS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	043382	OTHER	KS	BCBS

General Provider Information

NPI Number	:	1578535654
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DRS. COOPER & BANNINGER, LLC.

Provider Business Mailing Address
First Line	:	112 W MAIN ST
Second Line	:
City	:	BELOIT
State	:	KS
Zip	:	67420-2745
Country	:	US
Telephone Number	:	785-738-4200
Fax Number	:	785-738-4201

Provider Business Practice Location Address
First Line	:	112 W MAIN ST
Second Line	:
City	:	BELOIT
State	:	KS
Zip	:	67420-2745
Country	:	US
Telephone Number	:	785-738-4200
Fax Number	:	785-738-4201

Authorized Official
Title or Position	:	OWNER/OPTOMETRIST
Name	:	DR. DAVID LAWRENCE COOPER
Credential	:	O.D.
Telephone Number	:	785-823-6391

Provider Enumeration Date	:	02/03/2006
Last Update Date	:	08/22/2020

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