Provider Demographics
NPI:1861505877
Name:COOPER, MICHAEL ROSS (DC)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:ROSS
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 1:12217 SANTA MONICA BLVD
Mailing Address - Street 2:SUITE 208
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-2589
Mailing Address - Country:US
Mailing Address - Phone:310-447-3540
Mailing Address - Fax:310-447-3542
Practice Address - Street 1:12217 SANTA MONICA BLVD
Practice Address - Street 2:SUITE 208
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-2581
Practice Address - Country:US
Practice Address - Phone:310-447-3540
Practice Address - Fax:310-447-3542
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2015-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC20147111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW19148Medicare ID - Type Unspecified