Provider Demographics
NPI:1629426911
Name:COOPER, LATINA
Entity Type:Individual
Prefix:
First Name:LATINA
Middle Name:
Last Name:COOPER
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 1:912 E LAKE ST UPPR
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60506-5953
Mailing Address - Country:US
Mailing Address - Phone:630-999-6215
Mailing Address - Fax:
Practice Address - Street 1:912 E LAKE ST UPPR
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60506-5953
Practice Address - Country:US
Practice Address - Phone:630-999-6215
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-27
Last Update Date:2016-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle