=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740485572
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | R.M. HESTON OD PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/20/2007
-----------------------------------------------------
Last Update Date | 03/14/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1411 4TH SW
-----------------------------------------------------
City | MASON CITY
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50401
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 641-423-7555
-----------------------------------------------------
Fax | 641-423-8291
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1411 4TH SW
-----------------------------------------------------
City | MASON CITY
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50401
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 641-423-7555
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DOCTOR/OWNER
-----------------------------------------------------
Name | ROBERT MICHAEL HESTON
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 641-423-7555
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 01526
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------