Provider Demographics
NPI:1548497605
Name:COOPER, DARYL LEE (DC)
Entity type:Individual
Prefix:DR
First Name:DARYL
Middle Name:LEE
Last Name:COOPER
Suffix:
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 1:2920 ENLOE ST STE 105
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:WI
Mailing Address - Zip Code:54016-8191
Mailing Address - Country:US
Mailing Address - Phone:715-808-0716
Mailing Address - Fax:715-808-0807
Practice Address - Street 1:2920 ENLOE ST STE 105
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:WI
Practice Address - Zip Code:54016-8191
Practice Address - Country:US
Practice Address - Phone:715-808-0716
Practice Address - Fax:715-808-0807
Is Sole Proprietor?:No
Enumeration Date:2009-06-16
Last Update Date:2017-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1740111N00000X
WI1664-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor