Provider Demographics
NPI:1750399069
Name:COOK, LACY HOLT JR (DC)
Entity type:Individual
Prefix:
First Name:LACY
Middle Name:HOLT
Last Name:COOK
Suffix:JR
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 698
Mailing Address - Street 2:ATTN LACY COOK
Mailing Address - City:OSWEGO
Mailing Address - State:IL
Mailing Address - Zip Code:60543-0698
Mailing Address - Country:US
Mailing Address - Phone:630-554-3578
Mailing Address - Fax:630-554-3792
Practice Address - Street 1:57 W VAN BUREN ST
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:IL
Practice Address - Zip Code:60543-7213
Practice Address - Country:US
Practice Address - Phone:630-554-3578
Practice Address - Fax:630-554-3792
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
4782002OtherBC/BS
259780Medicare ID - Type Unspecified
4782002OtherBC/BS