MEDICARE: COOPER WELLNESS CHIROPRACTIC CENTER INC

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	111N00000X	Chiropractor	20147	CA

General Provider Information

NPI Number	:	1619168929
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COOPER WELLNESS CHIROPRACTIC CENTER INC

Provider Business Mailing Address
First Line	:	12217 SANTA MONICA BLVD STE 208
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90025-2581
Country	:	US
Telephone Number	:	310-447-3540
Fax Number	:	310-447-3542

Provider Business Practice Location Address
First Line	:	12217 SANTA MONICA BLVD STE 208
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90025-2589
Country	:	US
Telephone Number	:	310-447-3540
Fax Number	:	310-447-3542

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. MICHAEL ROSS COOPER
Credential	:	D.C.
Telephone Number	:	310-447-3540

Provider Enumeration Date	:	08/05/2007
Last Update Date	:	03/13/2015

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