Healthcare Provider Details

I. General information

NPI: 1952425498
Provider Name (Legal Business Name): HAYCOCK FOOT AND ANKLE CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/19/2007
Last Update Date: 01/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2311 BATON ROUGE
LIMA OH
45805-1129
US

IV. Provider business mailing address

2311 BATON ROUGE
LIMA OH
45805-1129
US

V. Phone/Fax

Practice location:
  • Phone: 419-228-3338
  • Fax: 419-228-3334
Mailing address:
  • Phone: 419-228-3338
  • Fax: 419-228-3334

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number36002946
License Number StateOH

VIII. Authorized Official

Name: DR. DARRYL MITCHELL HAYCOCK
Title or Position: DOCTOR
Credential: D.P.M.
Phone: 419-228-3338