Healthcare Provider Details

I. General information

NPI: 1922014521
Provider Name (Legal Business Name): COOPER CLINIC, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 09/01/2015
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:
Mailing address:
  • Phone: 479-274-2000
  • Fax: 479-274-2194

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License NumberMC-0254
License Number StateAR

VIII. Authorized Official

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