Provider Demographics
NPI:1841228368
Name:COOPER, TYRUS SANTEETLAH (DC)
Entity Type:Individual
Prefix:DR
First Name:TYRUS
Middle Name:SANTEETLAH
Last Name:COOPER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:476 MEETING ST STE C
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29403-4841
Mailing Address - Country:US
Mailing Address - Phone:843-723-6475
Mailing Address - Fax:843-722-4845
Practice Address - Street 1:476 MEETING ST STE C
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29403
Practice Address - Country:US
Practice Address - Phone:843-723-6475
Practice Address - Fax:843-722-4845
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-30
Last Update Date:2018-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2426111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1225134992Medicaid
SC46-5759177Medicaid