MEDICARE: KEVIN MICHAEL HECKSEL DPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2251X0800X	Orthopedic Physical Therapist	5501015360	MI
2	225100000X	Physical Therapist	5501015360	MI

General Provider Information

NPI Number	:	1063766491
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEVIN MICHAEL HECKSEL DPT

Provider Business Mailing Address
First Line	:	4761 LAKE MICHIGAN DR NW STE A
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49534-6300
Country	:	US
Telephone Number	:	616-791-7025
Fax Number	:	616-281-1221

Provider Business Practice Location Address
First Line	:	4761 LAKE MICHIGAN DR NW STE A
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49534-6300
Country	:	US
Telephone Number	:	616-891-7025
Fax Number	:	616-365-3174

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/07/2012
Last Update Date	:	07/06/2018

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