Provider Demographics
NPI:1689606436
Name:COOPER, CHARITA NICOLE (DC)
Entity Type:Individual
Prefix:MRS
First Name:CHARITA
Middle Name:NICOLE
Last Name:COOPER
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16705 SQUARE DR
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43040-8476
Mailing Address - Country:US
Mailing Address - Phone:937-642-4400
Mailing Address - Fax:937-642-4443
Practice Address - Street 1:16705 SQUARE DR
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:OH
Practice Address - Zip Code:43040-8722
Practice Address - Country:US
Practice Address - Phone:937-642-4400
Practice Address - Fax:937-642-4443
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2013-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3186111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2326049Medicaid
OH4073791Medicare ID - Type Unspecified