MEDICARE: LEO FRANK HETTIGER OPTOMETRIST

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	152WS0006X	Sports Vision Optometrist	046007547	IL
2	152WS0006X	Sports Vision Optometrist	T02518	MO

General Provider Information

NPI Number	:	1821052846
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LEO FRANK HETTIGER OPTOMETRIST

Provider Business Mailing Address
First Line	:	1205 N OLIVE RD
Second Line	:
City	:	FLORA
State	:	IL
Zip	:	62839-2344
Country	:	US
Telephone Number	:	618-662-4045
Fax Number	:	618-662-3402

Provider Business Practice Location Address
First Line	:	1205 N OLIVE RD
Second Line	:
City	:	FLORA
State	:	IL
Zip	:	62839-2344
Country	:	US
Telephone Number	:	618-662-4045
Fax Number	:	618-662-3402

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

Provider Enumeration Date	:	04/14/2006
Last Update Date	:	02/28/2013

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Directions to “ LEO FRANK HETTIGER OPTOMETRIST” Practice Location

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