Healthcare Provider Details

I. General information

NPI: 1326553512
Provider Name (Legal Business Name): CARLOS HAYCOCK RN, LAC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/10/2017
Last Update Date: 12/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2320 WOOLSEY ST STE 100
BERKELEY CA
94705-1974
US

IV. Provider business mailing address

4908 THUNDERHEAD CT
RICHMOND CA
94803-2144
US

V. Phone/Fax

Practice location:
  • Phone: 415-297-1129
  • Fax:
Mailing address:
  • Phone: 415-297-1129
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number17602
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: