Basic Information
| Provider Information | |||||||||
| NPI: | 1316336761 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COOPER CLINIC, PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7301 ROGERS AVE | ||||||||
| Address2: | |||||||||
| City: | FORT SMITH | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729034100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4792742000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6801 ROGERS AVE | ||||||||
| Address2: | |||||||||
| City: | FORT SMITH | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729034067 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4792742000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2015 | ||||||||
| LastUpdateDate: | 01/22/2015 | ||||||||
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| AuthorizedOfficialLastName: | RALSTON | ||||||||
| AuthorizedOfficialFirstName: | CURTIS | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4792742001 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1835X0200X | E3603 | AR | Y | 193200000X MULTI-SPECIALTY GROUP | Pharmacy Service Providers | Pharmacist | Oncology |
No ID Information.