Healthcare Provider Details

I. General information

NPI: 1639517154
Provider Name (Legal Business Name): CHARLEEN COOK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2013
Last Update Date: 06/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1668 LOWELL BETHESDA RD APT B
GASTONIA NC
28056-7325
US

IV. Provider business mailing address

1668 LOWELL BETHESDA RD APT B
GASTONIA NC
28056-7325
US

V. Phone/Fax

Practice location:
  • Phone: 951-743-9542
  • Fax:
Mailing address:
  • Phone: 951-743-9542
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171R00000X
TaxonomyInterpreter
License Number33141021
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: