Provider Demographics
NPI:1427671643
Name:COOPER, REGINA F
Entity type:Individual
Prefix:
First Name:REGINA
Middle Name:F
Last Name:COOPER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2627 NE 203RD ST STE 109
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33180-1945
Mailing Address - Country:US
Mailing Address - Phone:954-661-7227
Mailing Address - Fax:305-682-8994
Practice Address - Street 1:2627 NE 203RD ST STE 109
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33180-1945
Practice Address - Country:US
Practice Address - Phone:954-661-7227
Practice Address - Fax:305-682-8994
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-21
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL10D2181154291U00000X, 247ZC0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
No247ZC0005XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyClinical Laboratory Director, Non-physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL10D2181154OtherCLIA NUMBER
FL13-64-2027757OtherBIOMEDICAL WASTE CLINICAL LABORATORY
FL2-15OtherHEALTH, LIFE, ANNUITIES AND VARIABLE CONTRACTS
FL6011757OtherHEALTH CARE CLINIC ESTABLISHMENT