=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215442876
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COOKE CHIROPRACTIC CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/05/2017
-----------------------------------------------------
Last Update Date | 12/05/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16769 BERNARDO CENTER DR STE 21
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92128-2548
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-675-0007
-----------------------------------------------------
Fax | 858-284-3646
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16769 BERNARDO CENTER DR STE 21
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92128-2548
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-675-0007
-----------------------------------------------------
Fax | 858-284-3646
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | IAN CHRISTIAN COOKE
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 858-675-0007
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 33089
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------