MEDICARE: LACY HOLT COOK JR. D.C.

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		IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	4782002	OTHER		BC/BS

General Provider Information

NPI Number	:	1750399069
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LACY HOLT COOK JR. D.C.

Provider Business Mailing Address
First Line	:	PO BOX 698
Second Line	:	ATTN LACY COOK
City	:	OSWEGO
State	:	IL
Zip	:	60543-0698
Country	:	US
Telephone Number	:	630-554-3578
Fax Number	:	630-554-3792

Provider Business Practice Location Address
First Line	:	57 W VAN BUREN ST
Second Line	:
City	:	OSWEGO
State	:	IL
Zip	:	60543-7213
Country	:	US
Telephone Number	:	630-554-3578
Fax Number	:	630-554-3792

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

Provider Enumeration Date	:	08/03/2006
Last Update Date	:	07/08/2007

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