Provider Demographics
NPI:1821610288
Name:COOPER, LAWRENCE ANDREW (SOLE PROPRIETOR)
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:ANDREW
Last Name:COOPER
Suffix:
Gender:M
Credentials:SOLE PROPRIETOR
Other - Prefix:
Other - First Name:LAWRENCE
Other - Middle Name:ANDREW
Other - Last Name:COOPER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:ATTENDANT INDIVIDUAL
Mailing Address - Street 1:220 REEDY RIVER CT
Mailing Address - Street 2:
Mailing Address - City:ROEBUCK
Mailing Address - State:SC
Mailing Address - Zip Code:29376-3371
Mailing Address - Country:US
Mailing Address - Phone:864-641-9200
Mailing Address - Fax:
Practice Address - Street 1:220 REEDY RIVER CT
Practice Address - Street 2:
Practice Address - City:ROEBUCK
Practice Address - State:SC
Practice Address - Zip Code:29376-3371
Practice Address - Country:US
Practice Address - Phone:864-641-9200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-08
Last Update Date:2020-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCEA6001Medicaid
SCEA6002Medicaid