Provider Demographics
NPI:1053183616
Name:BENTZ, COOPER L
Entity type:Individual
Prefix:
First Name:COOPER
Middle Name:L
Last Name:BENTZ
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 1:2662 N ALVERNON WAY
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712-1750
Mailing Address - Country:US
Mailing Address - Phone:949-463-3670
Mailing Address - Fax:
Practice Address - Street 1:2662 N ALVERNON WAY APT D230
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-1740
Practice Address - Country:US
Practice Address - Phone:949-463-3670
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-26
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist