Provider Demographics
NPI:1396861423
Name:COOPER, CHERYL BETH (RDO)
Entity type:Individual
Prefix:MRS
First Name:CHERYL
Middle Name:BETH
Last Name:COOPER
Suffix:
Gender:F
Credentials:RDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1485-EL CAMINO REAL AVE.
Mailing Address - Street 2:SUITE 207
Mailing Address - City:BELMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94002-3318
Mailing Address - Country:US
Mailing Address - Phone:650-551-1755
Mailing Address - Fax:
Practice Address - Street 1:1485 EL CAMIN0 REAL
Practice Address - Street 2:SUITE 207
Practice Address - City:BELMONT
Practice Address - State:CA
Practice Address - Zip Code:94002-3318
Practice Address - Country:US
Practice Address - Phone:650-551-1755
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD6732156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician