=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952425498
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HAYCOCK FOOT AND ANKLE CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/19/2007
-----------------------------------------------------
Last Update Date | 01/24/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2311 BATON ROUGE
-----------------------------------------------------
City | LIMA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45805-1129
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-228-3338
-----------------------------------------------------
Fax | 419-228-3334
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2311 BATON ROUGE
-----------------------------------------------------
City | LIMA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45805-1129
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-228-3338
-----------------------------------------------------
Fax | 419-228-3334
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DOCTOR
-----------------------------------------------------
Name | DR. DARRYL MITCHELL HAYCOCK
-----------------------------------------------------
Credential | D.P.M.
-----------------------------------------------------
Telephone | 419-228-3338
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number | 36002946
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------