MEDICARE: DR. STEPHANIE HEAVENER DENTON D.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	2009000021	MO

General Provider Information

NPI Number	:	1326284860
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. STEPHANIE HEAVENER DENTON D.C.

Provider Business Mailing Address
First Line	:	1000 LAKE SAINT LOUIS BLVD
Second Line	:	SUITE 100
City	:	LAKE ST LOUIS
State	:	MO
Zip	:	63367-1340
Country	:	US
Telephone Number	:	636-695-4570
Fax Number	:	636-625-4554

Provider Business Practice Location Address
First Line	:	1000 LAKE SAINT LOUIS BLVD
Second Line	:	SUITE 100
City	:	LAKE ST LOUIS
State	:	MO
Zip	:	63367-1340
Country	:	US
Telephone Number	:	636-695-4570
Fax Number	:	636-625-4554

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/06/2009
Last Update Date	:	01/06/2009

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