Provider Demographics
NPI:1942326954
Name:HASELDEN, ROBERT KELLY SR (DC)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:KELLY
Last Name:HASELDEN
Suffix:SR
Gender:M
Credentials:DC
Other - Prefix:DR
Other - First Name:ROBERT
Other - Middle Name:K
Other - Last Name:HASELDEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA
Mailing Address - Street 1:402 ALTMAN ST
Mailing Address - Street 2:
Mailing Address - City:MONCKS CORNER
Mailing Address - State:SC
Mailing Address - Zip Code:29461-3652
Mailing Address - Country:US
Mailing Address - Phone:843-761-8522
Mailing Address - Fax:843-761-8560
Practice Address - Street 1:402 ALTMAN ST
Practice Address - Street 2:
Practice Address - City:MONCKS CORNER
Practice Address - State:SC
Practice Address - Zip Code:29461-3652
Practice Address - Country:US
Practice Address - Phone:843-761-8522
Practice Address - Fax:843-761-8560
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2012-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC627111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
155013700OtherOWCP
155013700OtherOWCP
T248230281Medicare ID - Type Unspecified