Provider Demographics
NPI:1285711366
Name:HANCOCK, KEVIN DALE (DC)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:DALE
Last Name:HANCOCK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6910 N MAIN ST
Mailing Address - Street 2:UNIT 5
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-8845
Mailing Address - Country:US
Mailing Address - Phone:574-271-1111
Mailing Address - Fax:
Practice Address - Street 1:6910 N MAIN ST
Practice Address - Street 2:UNIT 5
Practice Address - City:GRANGER
Practice Address - State:IN
Practice Address - Zip Code:46530-8845
Practice Address - Country:US
Practice Address - Phone:574-271-1111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2015-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08001251111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200022950AMedicaid
INU05224Medicare UPIN
IN200022950AMedicaid