Healthcare Provider Details

I. General information

NPI: 1801217609
Provider Name (Legal Business Name): CHAD COOK LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/20/2013
Last Update Date: 12/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 CARILLON PKWY STE 130
ST PETERSBURG FL
33716-1290
US

IV. Provider business mailing address

1716 MADRID DR
LARGO FL
33778-1244
US

V. Phone/Fax

Practice location:
  • Phone: 727-202-1222
  • Fax: 727-674-0726
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA 74048
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: