Provider Demographics
NPI:1003956533
Name:COOLEY, MARY CLARE (DC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:CLARE
Last Name:COOLEY
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5722 HOMESTEAD RD
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55804-9661
Mailing Address - Country:US
Mailing Address - Phone:218-525-3630
Mailing Address - Fax:218-525-3914
Practice Address - Street 1:5722 HOMESTEAD RD
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55804-9661
Practice Address - Country:US
Practice Address - Phone:218-525-3630
Practice Address - Fax:218-525-3630
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2007-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2079111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN70913COOtherBCBS
T65422Medicare UPIN