Healthcare Provider Details

I. General information

NPI: 1477588655
Provider Name (Legal Business Name): KENNETH BRYAN HELLER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 08/23/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 WILDWOOD DR
BELTON SC
29627-9687
US

IV. Provider business mailing address

PO BOX 846
BELTON SC
29627-0846
US

V. Phone/Fax

Practice location:
  • Phone: 864-940-9701
  • Fax: 864-338-8760
Mailing address:
  • Phone: 864-940-9701
  • Fax: 864-338-8760

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number09331
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: