MEDICARE: MRS. SANDRA RENEE COOPER RPSGT

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	246Z00000X	Other Specialist/Technologist	13706	FL

General Provider Information

NPI Number	:	1679938872
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SANDRA RENEE COOPER RPSGT

Provider Business Mailing Address
First Line	:	4716 GLASS MOUNTAIN DR
Second Line	:
City	:	KILLEEN
State	:	TX
Zip	:	76542-8355
Country	:	US
Telephone Number	:	352-321-1732
Fax Number	:

Provider Business Practice Location Address
First Line	:	761 TANK BATTALION
Second Line	:	BLDG. 412
City	:	FORT HOOD
State	:	TX
Zip	:	76544-4906
Country	:	US
Telephone Number	:	254-553-7720
Fax Number	:	254-553-7724

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

Provider Enumeration Date	:	12/15/2015
Last Update Date	:	12/15/2015

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