=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073976122
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHARITY COOPER
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/05/2016
-----------------------------------------------------
Last Update Date | 04/05/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3102 PLANTATION DR APT 2
-----------------------------------------------------
City | BARDSTOWN
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40004-9719
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-601-7255
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3102 PLANTATION DR APT 2
-----------------------------------------------------
City | BARDSTOWN
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40004-9719
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-601-7255
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | 500242
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 253Z00000X
-----------------------------------------------------
Taxonomy Name | In Home Supportive Care Agency
-----------------------------------------------------
License Number | 500242
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------