MEDICARE: MR. JEFFREY CHAD COOK I.D.C

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	1710I1002X	Independent Duty Corpsman
2	1710I1003X	Independent Duty Medical Technicians

General Provider Information

NPI Number	:	1437345279
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JEFFREY CHAD COOK I.D.C

Provider Business Mailing Address
First Line	:	MCM CREW IMPERVIOUS
Second Line	:	MEDICAL DEPARTMENT
City	:	FPO
State	:	AE
Zip	:	09501 1901
Country	:	US
Telephone Number	:	361-438-1994
Fax Number	:

Provider Business Practice Location Address
First Line	:	MCM CREW IMPERVIOUS
Second Line	:	MEDICAL DEPARTMENT
City	:	FPO
State	:	AE
Zip	:	09501 1901
Country	:	US
Telephone Number	:	361-438-1994
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/14/2007
Last Update Date	:	04/20/2008

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