1851521710 NPI number — RACHEL DIANE COOLEY P.T.

Table of content: MICHELLE FOGLE COTA / L (NPI 1134992308)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1851521710 NPI number — RACHEL DIANE COOLEY P.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COOLEY
Provider First Name:
RACHEL
Provider Middle Name:
DIANE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
P.T.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LEWELLING
Provider Other First Name:
RACHEL
Provider Other Middle Name:
DIANE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1851521710
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3675
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SHAWNEE
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74802-3675
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
405-214-0300
Provider Business Mailing Address Fax Number:
405-214-0301

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2506 N HARRISON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHAWNEE
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74804-3131
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-214-0300
Provider Business Practice Location Address Fax Number:
405-214-0301
Provider Enumeration Date:
07/24/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  4220 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 4220 . This is a "PT LICENSE" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".
  • Identifier: 200257240A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1851521710 . This is a "NPI" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".