1639268576 NPI number — BRENT LANE COOPER LPT

Table of content: BRENT LANE COOPER LPT (NPI 1639268576)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639268576 NPI number — BRENT LANE COOPER LPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COOPER
Provider First Name:
BRENT
Provider Middle Name:
LANE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LPT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1639268576
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3404 HILLSIDE DRIVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
URBANDALE
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
50322
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
515-278-1707
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
CENTRAL REHABILITATION, LTD
Provider Second Line Business Practice Location Address:
950 OFFICE PARK ROAD, SUITE 100
Provider Business Practice Location Address City Name:
WEST DES MOINES
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
50265
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
515-224-0979
Provider Business Practice Location Address Fax Number:
515-223-3862
Provider Enumeration Date:
10/11/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  01362 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)