Provider Demographics
NPI:1801977400
Name:MAYCOCK, KIRSTEN KIM (DC)
Entity type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:KIM
Last Name:MAYCOCK
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 S OSBORNE AVE
Mailing Address - Street 2:
Mailing Address - City:GILLETTE
Mailing Address - State:WY
Mailing Address - Zip Code:82716-3937
Mailing Address - Country:US
Mailing Address - Phone:307-682-4000
Mailing Address - Fax:307-686-0768
Practice Address - Street 1:207 S OSBORNE AVE
Practice Address - Street 2:
Practice Address - City:GILLETTE
Practice Address - State:WY
Practice Address - Zip Code:82716-3937
Practice Address - Country:US
Practice Address - Phone:307-682-4000
Practice Address - Fax:307-686-0768
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2015-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY586111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYW9963Medicare PIN