Healthcare Provider Details

I. General information

NPI: 1417298043
Provider Name (Legal Business Name): KENNETH SHANE HAGGARD L.AC.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/06/2013
Last Update Date: 03/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5610 CRAWFORDSVILLE RD BUILDING 1 SUITE 103
INDIANAPOLIS IN
46224-3727
US

IV. Provider business mailing address

5610 CRAWFORDSVILLE RD BUILDING 1 SUITE 103
INDIANAPOLIS IN
46224-3727
US

V. Phone/Fax

Practice location:
  • Phone: 317-240-8009
  • Fax:
Mailing address:
  • Phone: 317-240-8009
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number84000068A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: