Provider Demographics
NPI:1851042659
Name:COOPER, TIMOTHY WILLIAM (DC)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:WILLIAM
Last Name:COOPER
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 1:401 SW PARK ST
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:IL
Mailing Address - Zip Code:61727-2117
Mailing Address - Country:US
Mailing Address - Phone:217-454-2868
Mailing Address - Fax:
Practice Address - Street 1:211 S QUINCY ST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:IL
Practice Address - Zip Code:61727-1953
Practice Address - Country:US
Practice Address - Phone:217-935-6555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-12
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038.013826111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty