Provider Demographics
NPI:1629532502
Name:COOPER, LEROY DOUGLASS JR
Entity Type:Individual
Prefix:
First Name:LEROY
Middle Name:DOUGLASS
Last Name:COOPER
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2012 CALIFORNIA AVE
Mailing Address - Street 2:
Mailing Address - City:WHITE OAK
Mailing Address - State:PA
Mailing Address - Zip Code:15131-2322
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2012 CALIFORNIA AVE
Practice Address - Street 2:
Practice Address - City:WHITE OAK
Practice Address - State:PA
Practice Address - Zip Code:15131-2322
Practice Address - Country:US
Practice Address - Phone:724-518-6635
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-25
Last Update Date:2019-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer