1003040213 NPI number — KENNETH A HEILES, D.O. PLLC

Table of content: (NPI 1003040213)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003040213 NPI number — KENNETH A HEILES, D.O. PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KENNETH A HEILES, D.O. PLLC
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:
1003040213
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/28/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 310
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOUNTAIN HOME
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72654-0310
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-628-5110
Provider Business Mailing Address Fax Number:
870-628-5949

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
203 S JEFFERSON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STAR CITY
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
71667-5101
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-628-5110
Provider Business Practice Location Address Fax Number:
870-628-5949
Provider Enumeration Date:
05/04/2009

Additional Information

Authorized Official

Authorized Official Last Name:
HEILES
Authorized Official First Name:
KENNETH
Authorized Official Middle Name:
A
Authorized Official Title or Position:
OWNER/PHYSICIAN
Authorized Official Telephone Number:
870-628-5110

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  R3681 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 112297003 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com