Basic Information
| Provider Information | |||||||||
| NPI: | 1588117519 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COOPER CLINIC PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3528 | ||||||||
| Address2: | |||||||||
| City: | FORT SMITH | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729133528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4792742004 | ||||||||
| FaxNumber: | 4792742024 | ||||||||
| Practice Location | |||||||||
| Address1: | 6801 ROGERS AVE | ||||||||
| Address2: | |||||||||
| City: | FORT SMITH | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729034067 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4792742110 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2016 | ||||||||
| LastUpdateDate: | 07/26/2016 | ||||||||
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| AuthorizedOfficialLastName: | PAUL | ||||||||
| AuthorizedOfficialFirstName: | GAYLA | ||||||||
| AuthorizedOfficialMiddleName: | DENISE | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING & CONTRACT MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 4792742004 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | MC-0254 | AR | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.