=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255963526
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DAVID ROBERT HESTON BALLARD DC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/05/2020
-----------------------------------------------------
Last Update Date | 02/05/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 141 W PIONEER AVE
-----------------------------------------------------
City | HOMER
-----------------------------------------------------
State | AK
-----------------------------------------------------
Zip | 99603-7525
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 907-235-5173
-----------------------------------------------------
Fax | 907-235-7186
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 141 W PIONEER AVE
-----------------------------------------------------
City | HOMER
-----------------------------------------------------
State | AK
-----------------------------------------------------
Zip | 99603-7525
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 907-399-3144
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 156437
-----------------------------------------------------
License Number State | AK
-----------------------------------------------------