Provider Demographics
NPI:1083124473
Name:COOPER, MOSES (LAC)
Entity Type:Individual
Prefix:
First Name:MOSES
Middle Name:
Last Name:COOPER
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2240 SE 182ND AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97233-5608
Mailing Address - Country:US
Mailing Address - Phone:503-328-6259
Mailing Address - Fax:
Practice Address - Street 1:2240 SE 182ND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97233-5608
Practice Address - Country:US
Practice Address - Phone:503-328-6259
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-11
Last Update Date:2017-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC00886171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist