Provider Demographics
NPI:1588117519
Name:COOPER CLINIC PA
Entity type:Organization
Organization Name:COOPER CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING & CONTRACT MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:GAYLA
Authorized Official - Middle Name:DENISE
Authorized Official - Last Name:PAUL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-274-2004
Mailing Address - Street 1:PO BOX 3528
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72913-3528
Mailing Address - Country:US
Mailing Address - Phone:479-274-2004
Mailing Address - Fax:479-274-2024
Practice Address - Street 1:6801 ROGERS AVE
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-4067
Practice Address - Country:US
Practice Address - Phone:479-274-2110
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-26
Last Update Date:2016-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARMC-0254225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty