MEDICARE: TREVA MARIE COOPER RN

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	163WD0400X	Diabetes Educator Registered Nurse	653901	TX

General Provider Information

NPI Number	:	1790041838
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TREVA MARIE COOPER RN

Provider Business Mailing Address
First Line	:	PO BOX 88361
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77288-0361
Country	:	US
Telephone Number	:	832-393-4929
Fax Number	:	832-393-5255

Provider Business Practice Location Address
First Line	:	8000 N STADIUM DR
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77054-1823
Country	:	US
Telephone Number	:	832-393-4929
Fax Number	:	832-393-5255

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

Provider Enumeration Date	:	04/03/2012
Last Update Date	:	04/03/2012

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