Provider Demographics
NPI:1801915889
Name:COOPER CHIROPRACTIC AND NEUROLOGICAL DIAGNOSTIC CENTER PA
Entity type:Organization
Organization Name:COOPER CHIROPRACTIC AND NEUROLOGICAL DIAGNOSTIC CENTER PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:STANTON
Authorized Official - Middle Name:TUCKER
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:DC,DACAN
Authorized Official - Phone:321-726-8116
Mailing Address - Street 1:1501 ROBERT J CONLAN BLVD NE
Mailing Address - Street 2:SUITE 3
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32905-3502
Mailing Address - Country:US
Mailing Address - Phone:321-726-8116
Mailing Address - Fax:321-725-8535
Practice Address - Street 1:1501 ROBERT J CONLAN BLVD
Practice Address - Street 2:SUITE 3
Practice Address - City:NE PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32905-3502
Practice Address - Country:US
Practice Address - Phone:321-726-8116
Practice Address - Fax:321-725-8535
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-28
Last Update Date:2012-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH0003976111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL88902OtherBLUE CROSS
FL88902OtherBLUE CROSS
FL88902OtherBLUE CROSS
FL=========OtherTAX ID #