Basic Information
| Provider Information | |||||||||
| NPI: | 1366401812 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LAYCOCK | ||||||||
| FirstName: | CYNTHIA | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | O. D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | EASLEY | ||||||||
| OtherFirstName: | CYNTHIA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 286 | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 469750286 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5742233916 | ||||||||
| FaxNumber: | 5742232965 | ||||||||
| Practice Location | |||||||||
| Address1: | 2260 MAIN ST. | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 46975 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5742233916 | ||||||||
| FaxNumber: | 5742232965 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2006 | ||||||||
| LastUpdateDate: | 08/15/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 18003061A | IN | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 200377630 | 05 | IN | MEDICAID |