Provider Demographics
NPI:1134189202
Name:COOK, CHARLES R (D C)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:R
Last Name:COOK
Suffix:
Gender:M
Credentials:D C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 CREEK LN S
Mailing Address - Street 2:
Mailing Address - City:JORDAN
Mailing Address - State:MN
Mailing Address - Zip Code:55352-1202
Mailing Address - Country:US
Mailing Address - Phone:952-492-6363
Mailing Address - Fax:
Practice Address - Street 1:108 CREEK LN S
Practice Address - Street 2:
Practice Address - City:JORDAN
Practice Address - State:MN
Practice Address - Zip Code:55352-1202
Practice Address - Country:US
Practice Address - Phone:952-492-6363
Practice Address - Fax:952-492-5129
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-24
Last Update Date:2010-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3717111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN460717100Medicaid
MN73D29CHOtherBCBS OFFICE ID
MN35719800Medicaid
MN73D30COOtherBCBS PERSONAL ID
MN73D29CHOtherBCBS OFFICE ID
MN460717100Medicaid