Provider Demographics
NPI:1265796510
Name:COOMER, CAROLYN RUTH (ASSOCIATES)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:RUTH
Last Name:COOMER
Suffix:
Gender:F
Credentials:ASSOCIATES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1167 SPRATLIN PARK DR
Mailing Address - Street 2:
Mailing Address - City:GRAY
Mailing Address - State:TN
Mailing Address - Zip Code:37615-6205
Mailing Address - Country:US
Mailing Address - Phone:423-467-3600
Mailing Address - Fax:423-467-3644
Practice Address - Street 1:1400 WINDSOR AVE
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620-2070
Practice Address - Country:US
Practice Address - Phone:423-274-8100
Practice Address - Fax:423-274-8103
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-02
Last Update Date:2012-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver