Provider Demographics
NPI:1851446470
Name:COOP MANAGED HEALTH CARE LLC
Entity Type:Organization
Organization Name:COOP MANAGED HEALTH CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MISS
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:FULLER
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:704-719-0161
Mailing Address - Street 1:5028 ASHLEY LAKE DR
Mailing Address - Street 2:UNIT 331
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33437-3176
Mailing Address - Country:US
Mailing Address - Phone:704-719-0161
Mailing Address - Fax:
Practice Address - Street 1:5028 ASHLEY LAKE DRIVE
Practice Address - Street 2:UNIT 331
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33437
Practice Address - Country:US
Practice Address - Phone:704-719-0161
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2008-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN 9245770302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization