Basic Information
| Provider Information | |||||||||
| NPI: | 1043272917 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COOPER | ||||||||
| FirstName: | DARRELL | ||||||||
| MiddleName: | R. | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | ATC, LAT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 259 SHADY GROVE RD | ||||||||
| Address2: | |||||||||
| City: | ARKADELPHIA | ||||||||
| State: | AR | ||||||||
| PostalCode: | 719237305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8702308162 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1100 HENDERSON ST | ||||||||
| Address2: | |||||||||
| City: | ARKADELPHIA | ||||||||
| State: | AR | ||||||||
| PostalCode: | 719990001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8702305426 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/05/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | AT 354 | AR | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.