Provider Demographics
NPI:1366988461
Name:COOPER, WILLIAM (MACOM, LAC)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:
Last Name:COOPER
Suffix:
Gender:M
Credentials:MACOM, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:434 JUAN CT
Mailing Address - Street 2:
Mailing Address - City:MOAB
Mailing Address - State:UT
Mailing Address - Zip Code:84532-2125
Mailing Address - Country:US
Mailing Address - Phone:435-260-8005
Mailing Address - Fax:
Practice Address - Street 1:434 JUAN CT
Practice Address - Street 2:
Practice Address - City:MOAB
Practice Address - State:UT
Practice Address - Zip Code:84532-2125
Practice Address - Country:US
Practice Address - Phone:435-260-8005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-12
Last Update Date:2017-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT368174-1201171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist