MEDICARE: LAVINCE COOPER LMT. CMMP.

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	225700000X	Massage Therapist	MT-12125	AZ

General Provider Information

NPI Number	:	1932530110
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAVINCE COOPER LMT. CMMP.

Provider Business Mailing Address
First Line	:	35285 N KARAN SWISS CIR
Second Line	:
City	:	SAN TAN VALLEY
State	:	AZ
Zip	:	85143-4994
Country	:	US
Telephone Number	:	480-299-1194
Fax Number	:	480-882-9036

Provider Business Practice Location Address
First Line	:	35285 N KARAN SWISS CIR
Second Line	:
City	:	SAN TAN VALLEY
State	:	AZ
Zip	:	85143-4994
Country	:	US
Telephone Number	:	480-299-1194
Fax Number	:	480-882-9036

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

Provider Enumeration Date	:	12/12/2013
Last Update Date	:	12/12/2013

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