Provider Demographics
NPI:1942621743
Name:PEACOCK, KYLE (DC)
Entity Type:Individual
Prefix:DR
First Name:KYLE
Middle Name:
Last Name:PEACOCK
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 1:305 VIRGINIA ST
Mailing Address - Street 2:
Mailing Address - City:FORTVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46040-1069
Mailing Address - Country:US
Mailing Address - Phone:317-752-4297
Mailing Address - Fax:
Practice Address - Street 1:11773 COMMERCIAL DR
Practice Address - Street 2:
Practice Address - City:FISHERS
Practice Address - State:IN
Practice Address - Zip Code:46038-2904
Practice Address - Country:US
Practice Address - Phone:317-752-4297
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-20
Last Update Date:2013-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08002740A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor