Provider Demographics
NPI:1386204923
Name:AYCOCK, BERRY DEWAYNE (CPO)
Entity Type:Individual
Prefix:
First Name:BERRY
Middle Name:DEWAYNE
Last Name:AYCOCK
Suffix:
Gender:M
Credentials:CPO
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 4754
Mailing Address - Street 2:
Mailing Address - City:PINEHURST
Mailing Address - State:NC
Mailing Address - Zip Code:28374-4754
Mailing Address - Country:US
Mailing Address - Phone:910-295-2828
Mailing Address - Fax:910-295-2996
Practice Address - Street 1:325 PAGE RD N STE 3
Practice Address - Street 2:
Practice Address - City:PINEHURST
Practice Address - State:NC
Practice Address - Zip Code:28374-0088
Practice Address - Country:US
Practice Address - Phone:910-295-2828
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-17
Last Update Date:2019-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA02948224P00000X, 222Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
No224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist