MEDICARE: KEVIN M HADDOCK PT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	PT8063	CO

General Provider Information

NPI Number	:	1578548756
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEVIN M HADDOCK PT

Provider Business Mailing Address
First Line	:	4105 BRIARGATE PKWY
Second Line	:	STE 255
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80920-3480
Country	:	US
Telephone Number	:	719-282-2320
Fax Number	:	719-282-2330

Provider Business Practice Location Address
First Line	:	4105 BRIARGATE PKWY
Second Line	:	STE 255
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80920-3480
Country	:	US
Telephone Number	:	719-282-2320
Fax Number	:	719-282-2330

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/12/2005
Last Update Date	:	09/02/2010

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