Healthcare Provider Details

I. General information

NPI: 1093220659
Provider Name (Legal Business Name): CLINTON SCOTT COOK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/05/2017
Last Update Date: 12/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

188 SYCAMORE BRIDGE RD.
OLD FIELDS WV
26845-0925
US

IV. Provider business mailing address

PO BOX 925
OLD FIELDS WV
26845-0925
US

V. Phone/Fax

Practice location:
  • Phone: 304-851-7674
  • Fax:
Mailing address:
  • Phone: 304-851-7674
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: