Healthcare Provider Details

I. General information

NPI: 1629500616
Provider Name (Legal Business Name): ALEC HEFFNER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2017
Last Update Date: 03/30/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

459 E MAIN ST
VERSAILLES OH
45380-1525
US

IV. Provider business mailing address

459 E MAIN ST
VERSAILLES OH
45380-1525
US

V. Phone/Fax

Practice location:
  • Phone: 937-638-7049
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: