Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN1001X | Nutrition | CH6623 | FL |
NPI | 1528063757 |
---|---|
Provider Name | John Heiligenthal |
First Address | Eustis, FL 32726-6258 |
Second Address | Eustis, FL 32726-6258 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 15/06/2005 |
Last Update Date | 23/08/2010 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
U44335 | (02) | FL |