Provider Demographics
NPI:1417298043
Name:HAGGARD, KENNETH SHANE (LAC)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:SHANE
Last Name:HAGGARD
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5610 CRAWFORDSVILLE RD
Mailing Address - Street 2:BUILDING 1 SUITE 103
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46224-3727
Mailing Address - Country:US
Mailing Address - Phone:317-240-8009
Mailing Address - Fax:
Practice Address - Street 1:5610 CRAWFORDSVILLE RD
Practice Address - Street 2:BUILDING 1 SUITE 103
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46224-3727
Practice Address - Country:US
Practice Address - Phone:317-240-8009
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-06
Last Update Date:2013-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN84000068A171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist