Basic Information
| Provider Information | |||||||||
| NPI: | 1619589140 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOPERSKI | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | EILEEN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CHAVEZ | ||||||||
| OtherFirstName: | MICHELLE | ||||||||
| OtherMiddleName: | EILEEN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1022 JONABELL WAY | ||||||||
| Address2: | |||||||||
| City: | BEAUMONT | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922237055 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9512327930 | ||||||||
| FaxNumber: | 9092037403 | ||||||||
| Practice Location | |||||||||
| Address1: | 1481 WINDSOR DR | ||||||||
| Address2: | |||||||||
| City: | SAN BERNARDINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 924045416 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9093616470 | ||||||||
| FaxNumber: | 9092037403 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2020 | ||||||||
| LastUpdateDate: | 08/17/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 08/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 175T00000X | Y |
No ID Information.