Healthcare Provider Details

I. General information

NPI: 1578548756
Provider Name (Legal Business Name): KEVIN M HADDOCK PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2005
Last Update Date: 09/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4105 BRIARGATE PKWY STE 255
COLORADO SPRINGS CO
80920-3480
US

IV. Provider business mailing address

4105 BRIARGATE PKWY STE 255
COLORADO SPRINGS CO
80920-3480
US

V. Phone/Fax

Practice location:
  • Phone: 719-282-2320
  • Fax: 719-282-2330
Mailing address:
  • Phone: 719-282-2320
  • Fax: 719-282-2330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT8063
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: