=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861106973
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COOPER HEALTH MOBILE SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/12/2023
-----------------------------------------------------
Last Update Date | 01/12/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14632 BROTHERLY LANE
-----------------------------------------------------
City | CARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28278
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-770-6435
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14632 BROTHERLY LANE
-----------------------------------------------------
City | CHAROTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28278
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-770-6435
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FAMILY NURSE PRACTITIONER
-----------------------------------------------------
Name | MRS. RHONDA COOPER BRIDGET
-----------------------------------------------------
Credential | FNP-BC
-----------------------------------------------------
Telephone | 704-770-6435
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------