Provider Demographics
NPI:1649970104
Name:COOPER, WILLIE B III
Entity type:Individual
Prefix:
First Name:WILLIE
Middle Name:B
Last Name:COOPER
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6094 RIVER STYX RD
Mailing Address - Street 2:
Mailing Address - City:MEDINA
Mailing Address - State:OH
Mailing Address - Zip Code:44256-9782
Mailing Address - Country:US
Mailing Address - Phone:234-788-0323
Mailing Address - Fax:
Practice Address - Street 1:6094 RIVER STYX RD
Practice Address - Street 2:
Practice Address - City:MEDINA
Practice Address - State:OH
Practice Address - Zip Code:44256-9782
Practice Address - Country:US
Practice Address - Phone:234-788-0323
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-03
Last Update Date:2023-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide