MEDICARE: CHARLES COOPER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	594134	TX

General Provider Information

NPI Number	:	1578109963
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLES COOPER

Provider Business Mailing Address
First Line	:	4801 BRENTWOOD STAIR RD STE 404
Second Line	:
City	:	FT WORTH
State	:	TX
Zip	:	76103-1731
Country	:	US
Telephone Number	:	817-492-9383
Fax Number	:

Provider Business Practice Location Address
First Line	:	4801 BRENTWOOD STAIR RD STE 404
Second Line	:
City	:	FT WORTH
State	:	TX
Zip	:	76103-1731
Country	:	US
Telephone Number	:	817-492-9383
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/21/2019
Last Update Date	:	11/21/2019

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Directions to “ CHARLES COOPER ” Practice Location

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