=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861292989
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KOTLON M HEENAN
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/17/2025
-----------------------------------------------------
Last Update Date | 03/17/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7487 GRAND RIVER RD
-----------------------------------------------------
City | BRIGHTON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48114-9374
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 810-588-6314
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 320 HOLLY HILLS DR APT 621
-----------------------------------------------------
City | HOWELL
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48843-1925
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-358-4885
-----------------------------------------------------
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 | 2301401614
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------