Provider Demographics
NPI:1619507118
Name:AYCOCK, CALEB
Entity Type:Individual
Prefix:
First Name:CALEB
Middle Name:
Last Name:AYCOCK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:138 MATT PHILLIPS RD NW
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35806-2202
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:138 MATT PHILLIPS RD NW
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35806-2202
Practice Address - Country:US
Practice Address - Phone:256-324-9891
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-23
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
512659390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program