Healthcare Provider Details

I. General information

NPI: 1366655623
Provider Name (Legal Business Name): COOPER CLINIC PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2007
Last Update Date: 10/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 E MAIN ST
CHARLESTON AR
72933-9254
US

IV. Provider business mailing address

PO BOX 3528
FORT SMITH AR
72913-3528
US

V. Phone/Fax

Practice location:
  • Phone: 479-274-2000
  • Fax: 479-274-2194
Mailing address:
  • Phone: 479-274-2000
  • Fax: 479-274-2194

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMC-0254
License Number StateAR

VIII. Authorized Official

Name: CURTIS RALSTON
Title or Position: CEO
Credential:
Phone: 479-274-2000