Provider Demographics
NPI:1356649438
Name:COPPAGE, KIMBERLY
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:COPPAGE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:769 W BLAINE ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507-3970
Mailing Address - Country:US
Mailing Address - Phone:951-358-5186
Mailing Address - Fax:
Practice Address - Street 1:68-625 PEREZ RD
Practice Address - Street 2:11-A
Practice Address - City:CATHEDRAL CITY
Practice Address - State:CA
Practice Address - Zip Code:92234
Practice Address - Country:US
Practice Address - Phone:760-773-6767
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-14
Last Update Date:2015-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator