Healthcare Provider Details

I. General information

NPI: 1457215220
Provider Name (Legal Business Name): CODY HAYCOCK CRM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/15/2025
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 ISLAND AVE
LA GRANDE OR
97850-2940
US

IV. Provider business mailing address

2403 RIDDLE RD UNIT 10
LA GRANDE OR
97850-5336
US

V. Phone/Fax

Practice location:
  • Phone: 541-304-3205
  • Fax:
Mailing address:
  • Phone: 541-304-3205
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number25-CRM-4805
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: