MEDICARE: MR. WALTER EDWARD HEUCK

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	305S00000X	Point of Service

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	041253	OTHER	AZ	AHCCCS

General Provider Information

NPI Number	:	1609245323
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. WALTER EDWARD HEUCK

Provider Business Mailing Address
First Line	:	15113 W LAS BRIZAS LN
Second Line	:
City	:	SUN CITY WEST
State	:	AZ
Zip	:	85375-3056
Country	:	US
Telephone Number	:	602-576-7738
Fax Number	:

Provider Business Practice Location Address
First Line	:	15113 W LAS BRIZAS LN
Second Line	:
City	:	SUN CITY WEST
State	:	AZ
Zip	:	85375-3056
Country	:	US
Telephone Number	:	602-576-7738
Fax Number	:

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

Provider Enumeration Date	:	09/23/2015
Last Update Date	:	09/23/2015

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