Provider Demographics
NPI:1639268576
Name:COOPER, BRENT LANE (LPT)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:LANE
Last Name:COOPER
Suffix:
Gender:M
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3404 HILLSIDE DRIVE
Mailing Address - Street 2:
Mailing Address - City:URBANDALE
Mailing Address - State:IA
Mailing Address - Zip Code:50322
Mailing Address - Country:US
Mailing Address - Phone:515-278-1707
Mailing Address - Fax:
Practice Address - Street 1:CENTRAL REHABILITATION, LTD
Practice Address - Street 2:950 OFFICE PARK ROAD, SUITE 100
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50265
Practice Address - Country:US
Practice Address - Phone:515-224-0979
Practice Address - Fax:515-223-3862
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA01362225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist