Provider Demographics
NPI:1700167426
Name:COOPER, EVA
Entity Type:Individual
Prefix:
First Name:EVA
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 1:40 PENNINGTON DR
Mailing Address - Street 2:UNIT D
Mailing Address - City:BLUFFTON
Mailing Address - State:SC
Mailing Address - Zip Code:29910-6053
Mailing Address - Country:US
Mailing Address - Phone:843-227-1410
Mailing Address - Fax:
Practice Address - Street 1:1024 US HIGHWAY 80 W
Practice Address - Street 2:STE 206
Practice Address - City:POOLER
Practice Address - State:GA
Practice Address - Zip Code:31322-2188
Practice Address - Country:US
Practice Address - Phone:912-342-3036
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-08
Last Update Date:2021-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC90240174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist