Provider Demographics
NPI:1003945957
Name:COOPER, KEVIN WILLIAM (DC)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:WILLIAM
Last Name:COOPER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:681 MAIN STREET
Mailing Address - Street 2:SUITE 204
Mailing Address - City:PLACERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95667
Mailing Address - Country:US
Mailing Address - Phone:530-626-1181
Mailing Address - Fax:530-626-1087
Practice Address - Street 1:681 MAIN STREET
Practice Address - Street 2:SUITE 204
Practice Address - City:PLACERVILLE
Practice Address - State:CA
Practice Address - Zip Code:95667
Practice Address - Country:US
Practice Address - Phone:530-626-1181
Practice Address - Fax:530-626-1087
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC22312111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0223120Medicare ID - Type Unspecified