Healthcare Provider Details

I. General information

NPI: 1285814830
Provider Name (Legal Business Name): ROBERT CHARLTON COOPER OTR/L
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/13/2007
Last Update Date: 09/30/2024
Certification Date: 09/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6600 VAN AALST BLVD
FORT MOORE GA
31905-2102
US

IV. Provider business mailing address

6600 VAN AALST BLVD
FORT MOORE GA
31905-2102
US

V. Phone/Fax

Practice location:
  • Phone: 762-408-1617
  • Fax:
Mailing address:
  • Phone: 762-408-1617
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License NumberOT004016
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: