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General NPI Number Information
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NPI Number | 1023251691
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Entity Type | Organization
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Legal Business Name | HEIDI'S IMAGE ENHANCEMENT CLINIC
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Dates
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Enumeration Date | 04/13/2009
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Last Update Date | 04/13/2009
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Provider Practice Location Address
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Address Line | 2600 CENTRAL AVE SUITE E
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City | UNION CITY
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State | CA
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Zip | 94587-3187
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Country | US
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Telephone | 510-714-8392
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Fax |
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Provider Business Mailing Address
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Address Line | 32720 REGENTS BLVD
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City | UNION CITY
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State | CA
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Zip | 94587-5405
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Country | US
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Telephone | 510-489-8400
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Fax |
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Authorized Official
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Title or Position | OFFICE MANAGER/ LEA FITTER
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Name | MRS. HEIDI WHITE OATIS
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Credential | CMF
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Telephone | 510-489-8400
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 335E00000X
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Taxonomy Name | Prosthetic/Orthotic Supplier
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License Number | KK316787
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License Number State | CA
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