Healthcare Provider Details

I. General information

NPI: 1265345540
Provider Name (Legal Business Name): ALEXANDER LUCAS HEYEN ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2026
Last Update Date: 09/25/2026
Certification Date: 09/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 W RENNER RD APT 427
RICHARDSON TX
75080-1033
US

IV. Provider business mailing address

800 W RENNER RD APT 427
RICHARDSON TX
75080-1033
US

V. Phone/Fax

Practice location:
  • Phone: 217-556-4896
  • Fax:
Mailing address:
  • Phone: 217-556-4896
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT10563
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: