Provider Demographics
NPI:1902133788
Name:COOK, TONY GARRETT (LCP)
Entity Type:Individual
Prefix:
First Name:TONY
Middle Name:GARRETT
Last Name:COOK
Suffix:
Gender:M
Credentials:LCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 W MAIN ST
Mailing Address - Street 2:STE E
Mailing Address - City:CAMPBELLSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42718-2501
Mailing Address - Country:US
Mailing Address - Phone:270-465-8522
Mailing Address - Fax:270-465-8523
Practice Address - Street 1:610 W MAIN ST
Practice Address - Street 2:STE E
Practice Address - City:CAMPBELLSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42718-2501
Practice Address - Country:US
Practice Address - Phone:270-465-8522
Practice Address - Fax:270-465-8523
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-16
Last Update Date:2012-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYLP132335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100209830Medicaid
KY000000788517OtherATHEM BLUE CROSS AND BLUE SHIELD
KY6633030001Medicare NSC