Healthcare Provider Details

I. General information

NPI: 1821052846
Provider Name (Legal Business Name): LEO FRANK HETTIGER OPTOMETRIST
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/14/2006
Last Update Date: 02/28/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1205 N OLIVE RD
FLORA IL
62839-2344
US

IV. Provider business mailing address

1205 N OLIVE RD
FLORA IL
62839-2344
US

V. Phone/Fax

Practice location:
  • Phone: 618-662-4045
  • Fax: 618-662-3402
Mailing address:
  • Phone: 618-662-4045
  • Fax: 618-662-3402

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WS0006X
TaxonomySports Vision Optometrist
License Number046007547
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code152WS0006X
TaxonomySports Vision Optometrist
License NumberT02518
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: