Healthcare Provider Details

I. General information

NPI: 1295061430
Provider Name (Legal Business Name): ERIC HEFFERON P.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/22/2009
Last Update Date: 12/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19420N 59TH AVE E500
GLENDALE AZ
85308-6881
US

IV. Provider business mailing address

19420N 59TH AVE E500
GLENDALE AZ
85308-6881
US

V. Phone/Fax

Practice location:
  • Phone: 623-208-7575
  • Fax: 866-281-9664
Mailing address:
  • Phone: 602-639-1066
  • Fax: 866-281-9664

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number8663PT
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: