MEDICARE: MR. TIMOTHY L. COOK OPTICIAN

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	156FX1800X	Optician

General Provider Information

NPI Number	:	1750418117
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. TIMOTHY L. COOK OPTICIAN

Provider Business Mailing Address
First Line	:	68 E MAIN ST
Second Line	:
City	:	NORTH EAST
State	:	PA
Zip	:	16428-1339
Country	:	US
Telephone Number	:	814-725-4531
Fax Number	:

Provider Business Practice Location Address
First Line	:	68 E MAIN ST
Second Line	:
City	:	NORTH EAST
State	:	PA
Zip	:	16428-1339
Country	:	US
Telephone Number	:	814-725-4531
Fax Number	:

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

Provider Enumeration Date	:	02/27/2007
Last Update Date	:	07/08/2007

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