Provider Demographics
NPI:1114089109
Name:COOP, JUSTIN M (DC)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:M
Last Name:COOP
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24W788 75TH ST
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60565-1684
Mailing Address - Country:US
Mailing Address - Phone:630-465-6685
Mailing Address - Fax:630-445-0544
Practice Address - Street 1:24W788 75TH ST
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60565
Practice Address - Country:US
Practice Address - Phone:630-465-6685
Practice Address - Fax:630-445-0544
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2018-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-010123111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK12763OtherMEDICARE PIN
IL1841493111OtherGROUP NPI
ILV02614Medicare UPIN