Healthcare Provider Details

I. General information

NPI: 1972070191
Provider Name (Legal Business Name): BRYCE RANDAL HEFFINGTON OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/25/2018
Last Update Date: 10/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1350 E WOODHURST DR
SPRINGFIELD MO
65804-4281
US

IV. Provider business mailing address

PO BOX 774
SPRINGFIELD MO
65801-0774
US

V. Phone/Fax

Practice location:
  • Phone: 417-882-3937
  • Fax: 417-887-8551
Mailing address:
  • Phone: 417-869-3937
  • Fax: 417-869-0281

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2018038605
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: