MEDICARE: ZACHARY VINCINT HEASLEY

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	2255A2300X	Athletic Trainer
2	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1871033852
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ZACHARY VINCINT HEASLEY

Provider Business Mailing Address
First Line	:	111 E ROBINSON ST
Second Line	:
City	:	PADEN CITY
State	:	WV
Zip	:	26159-1730
Country	:	US
Telephone Number	:	304-771-5123
Fax Number	:

Provider Business Practice Location Address
First Line	:	111 E ROBINSON ST
Second Line	:
City	:	PADEN CITY
State	:	WV
Zip	:	26159-1730
Country	:	US
Telephone Number	:	304-771-5123
Fax Number	:

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

Provider Enumeration Date	:	02/24/2017
Last Update Date	:	02/24/2017

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