1356650030 NPI number — DALE PHILLIP COOPER CACI, CACII

Table of content: DALE PHILLIP COOPER CACI, CACII (NPI 1356650030)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356650030 NPI number — DALE PHILLIP COOPER CACI, CACII

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COOPER
Provider First Name:
DALE
Provider Middle Name:
PHILLIP
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CACI, CACII
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1356650030
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/29/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1623 SHADY OAK LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FLORENCE
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29506-9112
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-669-2496
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
510 E CAROLINA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HARTSVILLE
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29550-4312
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-332-4156
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/29/2010

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: 101YA0400X , with the licence number:  0909044 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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