Provider Demographics
NPI:1730707811
Name:KOPPER IMAGING
Entity type:Organization
Organization Name:KOPPER IMAGING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TAYLER
Authorized Official - Middle Name:
Authorized Official - Last Name:KOPPERUD
Authorized Official - Suffix:
Authorized Official - Credentials:RCS, RVS
Authorized Official - Phone:909-931-5885
Mailing Address - Street 1:222 N MOUNTAIN AVE STE 210
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-5714
Mailing Address - Country:US
Mailing Address - Phone:909-931-5885
Mailing Address - Fax:
Practice Address - Street 1:222 N MOUNTAIN AVE STE 210
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-5714
Practice Address - Country:US
Practice Address - Phone:909-931-5885
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-06
Last Update Date:2021-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0208XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mobile