Provider Demographics
NPI:1992009278
Name:COOPER, JOEL R JR
Entity type:Individual
Prefix:MR
First Name:JOEL
Middle Name:R
Last Name:COOPER
Suffix:JR
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 1:2617 S 600 W
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IN
Mailing Address - Zip Code:46953-9381
Mailing Address - Country:US
Mailing Address - Phone:765-603-6971
Mailing Address - Fax:
Practice Address - Street 1:2617 S 600 W
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46953-9381
Practice Address - Country:US
Practice Address - Phone:765-603-6971
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-31
Last Update Date:2010-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN8909098374343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)