Healthcare Provider Details

I. General information

NPI: 1003588732
Provider Name (Legal Business Name): DAVITA J COOK MT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2021
Last Update Date: 02/22/2022
Certification Date: 02/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4572 KAPP DR
HUBER HEIGHTS OH
45424-5921
US

IV. Provider business mailing address

4572 KAPP DR
HUBER HEIGHTS OH
45424-5921
US

V. Phone/Fax

Practice location:
  • Phone: 937-250-9938
  • Fax:
Mailing address:
  • Phone: 937-250-9938
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number1003588732
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code156F00000X
TaxonomyTechnician/Technologist
License Number1003588732
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code156F00000X
TaxonomyTechnician/Technologist
License Number6009038
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code225500000X
TaxonomyRespiratory/Developmental/Rehabilitative Specialist/Technologist
License Number1003588732
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: