Provider Demographics
NPI:1144486705
Name:COOPER FAMILY CHIROPRACTIC
Entity type:Organization
Organization Name:COOPER FAMILY CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARCY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:636-379-9105
Mailing Address - Street 1:9103 PHOENIX VILLAGE PKWY
Mailing Address - Street 2:SUITE F
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63368-4279
Mailing Address - Country:US
Mailing Address - Phone:636-265-2566
Mailing Address - Fax:866-418-4148
Practice Address - Street 1:9103 PHOENIX VILLAGE PKWY
Practice Address - Street 2:SUITE F
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63368-4279
Practice Address - Country:US
Practice Address - Phone:636-265-2566
Practice Address - Fax:866-418-4148
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-04
Last Update Date:2014-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000144756111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO38309OtherGHP/CMR
MO432179OtherHEALTHLINK
MO7997538OtherAETNA
MO139154OtherANTHEM BLUE CROSS BLUE SHIELD
MO139154OtherANTHEM BLUE CROSS BLUE SHIELD