Healthcare Provider Details

I. General information

NPI: 1396899944
Provider Name (Legal Business Name): MICHAEL S HEFFNER LAT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2007
Last Update Date: 07/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 TYLER CT
WENTZVILLE MO
63385-4665
US

IV. Provider business mailing address

19 TYLER CT
WENTZVILLE MO
63385-4665
US

V. Phone/Fax

Practice location:
  • Phone: 314-960-3812
  • Fax:
Mailing address:
  • Phone: 314-960-3812
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number116261
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: