=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306119276
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HEIB CHIROPRACTIC CLINIC, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/22/2012
-----------------------------------------------------
Last Update Date | 05/22/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2225 E CENTRE AVE
-----------------------------------------------------
City | PORTAGE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49002-4421
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-324-0100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2225 E CENTRE AVE
-----------------------------------------------------
City | PORTAGE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49002-4421
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-324-0100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIROPRACTOR
-----------------------------------------------------
Name | DR. ANDREW J HEIB
-----------------------------------------------------
Credential | CCSP
-----------------------------------------------------
Telephone | 269-324-0100
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111NS0005X
-----------------------------------------------------
Taxonomy Name | Sports Physician Chiropractor
-----------------------------------------------------
License Number | 6816
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------