Provider Information for 1700267143
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CARLY HEIDENREICH
Sex: Female
NPI: 1700267143
Last Updated: 2015-06-11
Certification Date:
Certification Date:
Details
| Name | Value | ||||||||
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| NPI | 1700267143 | ||||||||
| Enumeration Date | 2015-06-11 | ||||||||
| NPI Type | NPI-1 Individual | ||||||||
| Sole Proprietor | NO | ||||||||
| Status | Active | ||||||||
| Mailing Address | PO BOX 809 GOSHEN, IN 46527-0809 United States Phone: 574-533-1234 | Fax:574-537-2652 | ||||||||
| Primary Practice Address | 2600 OAKLAND AVE ELKHART, IN 46517-1533 United States Phone: 574-533-1234 | Fax:574-537-2652 | ||||||||
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