Provider Demographics
NPI:1073689618
Name:HAYCOCK CHIROPRACTIC PC
Entity Type:Organization
Organization Name:HAYCOCK CHIROPRACTIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:DALE
Authorized Official - Last Name:HAYCOCK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:208-855-2688
Mailing Address - Street 1:1773 S MILLENIUM WAY
Mailing Address - Street 2:
Mailing Address - City:MARIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1511
Mailing Address - Country:US
Mailing Address - Phone:208-855-2688
Mailing Address - Fax:208-855-2689
Practice Address - Street 1:1773 S MILLENIUM WAY
Practice Address - Street 2:
Practice Address - City:MARIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-1511
Practice Address - Country:US
Practice Address - Phone:208-855-2688
Practice Address - Fax:208-855-2689
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
Y98622Medicare UPIN