MEDICARE: DR. STANTON TUCKER COOPER DC, DACAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111NN0400X	Neurology Chiropractor	CH0003926	FL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	88902Z	OTHER	FL	MEDICARE

General Provider Information

NPI Number	:	1568542546
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. STANTON TUCKER COOPER DC, DACAN

Provider Business Mailing Address
First Line	:	1501 ROBERT J CONLAN BLVD NE
Second Line	:	SUITE 3
City	:	PALM BAY
State	:	FL
Zip	:	32905-3502
Country	:	US
Telephone Number	:	321-726-8116
Fax Number	:	321-726-8535

Provider Business Practice Location Address
First Line	:	1501 ROBERT J CONLAN BLVD NE
Second Line	:	SUITE 3
City	:	PALM BAY
State	:	FL
Zip	:	32905-3502
Country	:	US
Telephone Number	:	321-726-8116
Fax Number	:	321-726-8535

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/16/2006
Last Update Date	:	09/13/2007

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Directions to “ DR. STANTON TUCKER COOPER DC, DACAN” Practice Location

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