Provider Demographics
NPI:1295853588
Name:LAYCOCK, CHARLES M (DC)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:M
Last Name:LAYCOCK
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 1:614 S 225TH ST
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:WA
Mailing Address - Zip Code:98198-6843
Mailing Address - Country:US
Mailing Address - Phone:206-878-2225
Mailing Address - Fax:206-878-7488
Practice Address - Street 1:614 S 225TH ST
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:WA
Practice Address - Zip Code:98198-6843
Practice Address - Country:US
Practice Address - Phone:206-878-2225
Practice Address - Fax:206-878-7488
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA2398111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2398OtherWA STATE LICENSE NUMBER
WA60683OtherDEPT. OF L&I NUMBER
WA60683OtherDEPT. OF L&I NUMBER
WAT91793Medicare UPIN