Provider Demographics
NPI:1194902262
Name:COOPER, WILLIE JAMES
Entity type:Individual
Prefix:
First Name:WILLIE
Middle Name:JAMES
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 1:171 S 42ND ST
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:CA
Mailing Address - Zip Code:94804-3423
Mailing Address - Country:US
Mailing Address - Phone:510-215-0605
Mailing Address - Fax:
Practice Address - Street 1:820 23RD ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:CA
Practice Address - Zip Code:94804-1338
Practice Address - Country:US
Practice Address - Phone:510-229-5000
Practice Address - Fax:510-235-3112
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-30
Last Update Date:2008-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility