1568762953 NPI number — MICHAEL W HEASLET DPM INC

Table of content: (NPI 1568762953)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568762953 NPI number — MICHAEL W HEASLET DPM INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MICHAEL W HEASLET DPM INC
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:
1568762953
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/01/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4950 BARRANCA PKWY
Provider Second Line Business Mailing Address:
SUITE 308
Provider Business Mailing Address City Name:
IRVINE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92604-4671
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
949-651-1202
Provider Business Mailing Address Fax Number:
949-552-9493

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4950 BARRANCA PKWY
Provider Second Line Business Practice Location Address:
SUITE 308
Provider Business Practice Location Address City Name:
IRVINE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92604-4671
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
949-651-1202
Provider Business Practice Location Address Fax Number:
949-552-9493
Provider Enumeration Date:
11/01/2010

Additional Information

Authorized Official

Authorized Official Last Name:
HEASLET
Authorized Official First Name:
GAIL
Authorized Official Middle Name:
KATHLEEN
Authorized Official Title or Position:
CORPORATE SECRETARY
Authorized Official Telephone Number:
949-651-1202

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , with the licence number:  E2056 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1790735397 . This is a "TYPE 1 NPI" identifier . This identifiers is of the category "OTHER".




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