=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336596386
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROBERT HEINEMANN
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/19/2016
-----------------------------------------------------
Last Update Date | 05/19/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2401 OAK DR
-----------------------------------------------------
City | LONGWOOD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32779-4745
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-595-5457
-----------------------------------------------------
Fax | 407-772-0378
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 161941
-----------------------------------------------------
City | ALTAMONTE SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32716-1941
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-595-5457
-----------------------------------------------------
Fax | 407-772-0378
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171WH0202X
-----------------------------------------------------
Taxonomy Name | Home Modifications Contractor
-----------------------------------------------------
License Number | CGC058989
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------