Provider Demographics
NPI:1063187193
Name:COOPER, CLOTILDA D (OWNER)
Entity type:Individual
Prefix:
First Name:CLOTILDA
Middle Name:D
Last Name:COOPER
Suffix:
Gender:F
Credentials:OWNER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:905 S GARNETT ST UNIT 414
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NC
Mailing Address - Zip Code:27536-0170
Mailing Address - Country:US
Mailing Address - Phone:919-939-6147
Mailing Address - Fax:
Practice Address - Street 1:550 WEST ANDREWS AVE
Practice Address - Street 2:NUMBER 48
Practice Address - City:HENDERSON
Practice Address - State:NC
Practice Address - Zip Code:27536
Practice Address - Country:US
Practice Address - Phone:919-939-6147
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-11
Last Update Date:2021-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)