MEDICARE: COOP MANAGED HEALTH CARE LLC

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	302R00000X	Health Maintenance Organization	RN 9245770	FL

General Provider Information

NPI Number	:	1851446470
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COOP MANAGED HEALTH CARE LLC

Provider Business Mailing Address
First Line	:	5028 ASHLEY LAKE DR
Second Line	:	UNIT 331
City	:	BOYNTON BEACH
State	:	FL
Zip	:	33437-3176
Country	:	US
Telephone Number	:	704-719-0161
Fax Number	:

Provider Business Practice Location Address
First Line	:	5028 ASHLEY LAKE DRIVE
Second Line	:	UNIT 331
City	:	BOYNTON BEACH
State	:	FL
Zip	:	33437
Country	:	US
Telephone Number	:	704-719-0161
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MISS LINDA KAY FULLER
Credential	:	RN
Telephone Number	:	704-719-0161

Provider Enumeration Date	:	01/24/2007
Last Update Date	:	08/08/2008

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