Healthcare Provider Details

I. General information

NPI: 1043272917
Provider Name (Legal Business Name): DARRELL R. COOPER ATC, LAT
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 HENDERSON ST
ARKADELPHIA AR
71999-0001
US

IV. Provider business mailing address

259 SHADY GROVE RD
ARKADELPHIA AR
71923-7305
US

V. Phone/Fax

Practice location:
  • Phone: 870-230-5426
  • Fax:
Mailing address:
  • Phone: 870-230-8162
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT 354
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: