Provider Demographics
NPI:1972526432
Name:HAYCOCK, KENNETH ROBERT (DC)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:ROBERT
Last Name:HAYCOCK
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 1:276 FEDERAL AVE NW
Mailing Address - Street 2:
Mailing Address - City:MASSILLON
Mailing Address - State:OH
Mailing Address - Zip Code:44647-5469
Mailing Address - Country:US
Mailing Address - Phone:330-833-2085
Mailing Address - Fax:330-833-2067
Practice Address - Street 1:276 FEDERAL AVE NW
Practice Address - Street 2:
Practice Address - City:MASSILLON
Practice Address - State:OH
Practice Address - Zip Code:44647-5469
Practice Address - Country:US
Practice Address - Phone:330-833-2085
Practice Address - Fax:330-833-2067
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2009-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3515111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2517100Medicaid
OHQ044763OtherHOMETOWN
OH3515OtherOSCB
OH7509586OtherAETNA
OH000000491984OtherANTHEM BC/BS
OH4137003Medicare PIN