MEDICARE: MR. GLEN LAWRENCE COOPER ATC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	RT000248A	PA

General Provider Information

NPI Number	:	1891771887
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. GLEN LAWRENCE COOPER ATC

Provider Business Mailing Address
First Line	:	118 STONEYCREEK LN
Second Line	:
City	:	HARRISON CITY
State	:	PA
Zip	:	15636-1308
Country	:	US
Telephone Number	:	724-744-4974
Fax Number	:

Provider Business Practice Location Address
First Line	:	BOX 530, ROUTE 130
Second Line	:
City	:	HARRISON CITY
State	:	PA
Zip	:	15636
Country	:	US
Telephone Number	:	724-744-4471
Fax Number	:	724-744-1214

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/21/2005
Last Update Date	:	07/08/2007

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