1114063617 NPI number — HEFFRON CLINIC, P.C.

Table of content: (NPI 1114063617)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114063617 NPI number — HEFFRON CLINIC, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HEFFRON CLINIC, P.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114063617
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/06/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
755 HIGH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ADRIAN
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49221-1442
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
517-265-2175
Provider Business Mailing Address Fax Number:
517-264-5926

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
755 HIGH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ADRIAN
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49221-1442
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
517-265-2175
Provider Business Practice Location Address Fax Number:
517-264-5926
Provider Enumeration Date:
01/30/2007

Additional Information

Authorized Official

Authorized Official Last Name:
JAMES
Authorized Official First Name:
VERLIE
Authorized Official Middle Name:
B
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
517-265-8687

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2854819 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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