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General NPI Number Information
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NPI Number | 1538354964
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Entity Type | Organization
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Legal Business Name | JACK HEETHOUSE DO PLLC
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Dates
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Enumeration Date | 09/10/2007
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Last Update Date | 11/06/2007
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Provider Practice Location Address
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Address Line | 1675 LEAHY ST SUITE 120
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City | MUSKEGON
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State | MI
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Zip | 49442-5500
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Country | US
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Telephone | 231-722-7245
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Fax | 231-722-6103
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Provider Business Mailing Address
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Address Line | 1675 LEAHY ST SUITE 120
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City | MUSKEGON
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State | MI
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Zip | 49442-5500
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Country | US
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Telephone | 231-722-7245
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Fax | 231-722-6103
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Authorized Official
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Title or Position | OWNER
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Name | DR. JACK W HEETHOUSE
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Credential | DO
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Telephone | 231-722-7245
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207X00000X
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Taxonomy Name | Orthopaedic Surgery Physician
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License Number | 5101012999
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License Number State | MI
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