MEDICARE: COOPER FAMILY CHIROPRACTIC PLC

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	2301008406	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	950A312700	OTHER	MI	BCBSM

General Provider Information

NPI Number	:	1366740003
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COOPER FAMILY CHIROPRACTIC PLC

Provider Business Mailing Address
First Line	:	4071 W DICKMAN RD
Second Line	:
City	:	BATTLE CREEK
State	:	MI
Zip	:	49037-7551
Country	:	US
Telephone Number	:	269-274-5716
Fax Number	:

Provider Business Practice Location Address
First Line	:	4071 W DICKMAN RD
Second Line	:
City	:	BATTLE CREEK
State	:	MI
Zip	:	49037-7551
Country	:	US
Telephone Number	:	269-274-5716
Fax Number	:

Authorized Official
Title or Position	:	OWNER/DOCTOR
Name	:	DR. KENNETH WESLEY COOPER
Credential	:	DC
Telephone Number	:	269-274-5716

Provider Enumeration Date	:	03/04/2011
Last Update Date	:	03/18/2011

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