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General NPI Number Information
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NPI Number | 1669168696
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Entity Type | Individual
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Provider Name | MR. SAMUEL BERNELL COOKE
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Gender | Male
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Dates
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Enumeration Date | 04/13/2023
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Last Update Date | 04/13/2023
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Provider Practice Location Address
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Address Line | 142 TANGLEWOOD CV
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City | BELMONT
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State | NC
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Zip | 28012-7783
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Country | US
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Telephone | 803-448-1747
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Fax |
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Provider Business Mailing Address
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Address Line | 1875 STEGALL LN
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City | FORT MILL
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State | SC
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Zip | 29715-9724
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Country | US
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Telephone | 803-448-1747
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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