Healthcare Provider Details

I. General information

NPI: 1487830204
Provider Name (Legal Business Name): DENNIS HEASLEY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/10/2008
Last Update Date: 01/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

576 JEFFERSON AVE
FT EUSTIS VA
23604-5548
US

IV. Provider business mailing address

327 26TH ST APT H
FORT EUSTIS VA
23604-1140
US

V. Phone/Fax

Practice location:
  • Phone: 757-314-7666
  • Fax:
Mailing address:
  • Phone: 757-314-7666
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246Z00000X
TaxonomyOther Specialist/Technologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: