Healthcare Provider Details

I. General information

NPI: 1235588633
Provider Name (Legal Business Name): MICHAEL COOK ATC, LAT, CSCS, CKTP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2016
Last Update Date: 06/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 LONGVIEW DR
BEVERLY MA
01915-2614
US

IV. Provider business mailing address

12 LONGVIEW DR
BEVERLY MA
01915-2614
US

V. Phone/Fax

Practice location:
  • Phone: 978-578-4169
  • Fax: 978-524-0421
Mailing address:
  • Phone: 978-578-4169
  • Fax: 978-524-0421

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1158
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: