Provider Demographics
NPI:1982618898
Name:LENT KOOP, DANIEL MADISON (MPT, CHT)
Entity Type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:MADISON
Last Name:LENT KOOP
Suffix:
Gender:M
Credentials:MPT, CHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5817 RIO ANIMAS RD NE
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87144-4719
Mailing Address - Country:US
Mailing Address - Phone:505-206-4625
Mailing Address - Fax:
Practice Address - Street 1:3001 BROADMOOR BLVD NE
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87144-2100
Practice Address - Country:US
Practice Address - Phone:505-994-7131
Practice Address - Fax:505-994-7155
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2013-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10611006742251H1200X
NM4129225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251H1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistHand
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM4129OtherPT LICENSE
650001175OtherMEDICARE