Provider Demographics
NPI:1932869898
Name:COOPER, TOMMY
Entity Type:Individual
Prefix:
First Name:TOMMY
Middle Name:
Last Name:COOPER
Suffix:
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 1:3884 BUCKS OF GAINS CREEK RD
Mailing Address - Street 2:
Mailing Address - City:MCALESTER
Mailing Address - State:OK
Mailing Address - Zip Code:74501-7597
Mailing Address - Country:US
Mailing Address - Phone:918-424-1496
Mailing Address - Fax:
Practice Address - Street 1:1617 E ELECTRIC AVE
Practice Address - Street 2:
Practice Address - City:MCALESTER
Practice Address - State:OK
Practice Address - Zip Code:74501-3864
Practice Address - Country:US
Practice Address - Phone:918-424-1496
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-20
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK189580225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty