Provider Demographics
NPI:1649633520
Name:COOPER, CODY
Entity type:Individual
Prefix:
First Name:CODY
Middle Name:
Last Name:COOPER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:317 N EL CAMINO REAL
Mailing Address - Street 2:SUITE 210
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92024-2811
Mailing Address - Country:US
Mailing Address - Phone:760-634-0248
Mailing Address - Fax:760-634-1782
Practice Address - Street 1:1611 W MAIN ST
Practice Address - Street 2:
Practice Address - City:EL CENTRO
Practice Address - State:CA
Practice Address - Zip Code:92243-2212
Practice Address - Country:US
Practice Address - Phone:760-337-1144
Practice Address - Fax:760-337-8259
Is Sole Proprietor?:No
Enumeration Date:2016-03-30
Last Update Date:2016-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA43548225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist