Provider Demographics
NPI:1932530110
Name:COOPER, LAVINCE (LMT CMMP)
Entity Type:Individual
Prefix:
First Name:LAVINCE
Middle Name:
Last Name:COOPER
Suffix:
Gender:M
Credentials:LMT CMMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35285 N KARAN SWISS CIR
Mailing Address - Street 2:
Mailing Address - City:SAN TAN VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85143-4994
Mailing Address - Country:US
Mailing Address - Phone:480-299-1194
Mailing Address - Fax:480-882-9036
Practice Address - Street 1:35285 N KARAN SWISS CIR
Practice Address - Street 2:
Practice Address - City:SAN TAN VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85143-4994
Practice Address - Country:US
Practice Address - Phone:480-299-1194
Practice Address - Fax:480-882-9036
Is Sole Proprietor?:No
Enumeration Date:2013-12-12
Last Update Date:2013-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMT-12125225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist