Basic Information
Provider Information | |||||||||
NPI: | 1831105436 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | COOPER CLINIC, PA | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 3528 | ||||||||
Address2: |   | ||||||||
City: | FORT SMITH | ||||||||
State: | AR | ||||||||
PostalCode: | 729133528 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4792742000 | ||||||||
FaxNumber: | 4792742194 | ||||||||
Practice Location | |||||||||
Address1: | 4300 REGIONS PARK DR | ||||||||
Address2: |   | ||||||||
City: | FORT SMITH | ||||||||
State: | AR | ||||||||
PostalCode: | 729169373 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4792746300 | ||||||||
FaxNumber: | 4794844715 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/01/2006 | ||||||||
LastUpdateDate: | 09/01/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | RALSTON | ||||||||
AuthorizedOfficialFirstName: | CURTIS | ||||||||
AuthorizedOfficialMiddleName: | D | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 4792742000 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | MC-0254 | AR | Y |   | Ambulatory Health Care Facilities | Clinic/Center |   |
No ID Information.