Provider Demographics
NPI:1093220659
Name:COOK, CLINTON SCOTT
Entity type:Individual
Prefix:
First Name:CLINTON
Middle Name:SCOTT
Last Name:COOK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 925
Mailing Address - Street 2:
Mailing Address - City:OLD FIELDS
Mailing Address - State:WV
Mailing Address - Zip Code:26845-0925
Mailing Address - Country:US
Mailing Address - Phone:304-851-7674
Mailing Address - Fax:
Practice Address - Street 1:188 SYCAMORE BRIDGE RD.
Practice Address - Street 2:
Practice Address - City:OLD FIELDS
Practice Address - State:WV
Practice Address - Zip Code:26845-0925
Practice Address - Country:US
Practice Address - Phone:304-851-7674
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-05
Last Update Date:2017-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV23810030305Medicaid