Healthcare Provider Details

I. General information

NPI: 1649662628
Provider Name (Legal Business Name): JACK R MCCOY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2015
Last Update Date: 02/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 MERIDIAN PARKE DR
GREENWOOD IN
46142-9427
US

IV. Provider business mailing address

6000 S 150 W
LAFAYETTE IN
47909-8909
US

V. Phone/Fax

Practice location:
  • Phone: 765-883-9426
  • Fax: 765-884-9221
Mailing address:
  • Phone: 765-414-4789
  • Fax: 405-603-2207

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332S00000X
TaxonomyHearing Aid Equipment
License Number
License Number State

VIII. Authorized Official

Name: JACK MCCOY
Title or Position: OWNER
Credential:
Phone: 765-414-4789