Provider Demographics
NPI:1578642633
Name:HEETER, JAMES
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:HEETER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7201 E BASS LN
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-8902
Mailing Address - Country:US
Mailing Address - Phone:573-441-8541
Mailing Address - Fax:
Practice Address - Street 1:1431 SOUTHWEST BLVD
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-2468
Practice Address - Country:US
Practice Address - Phone:573-636-9104
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO00995OtherLICENSE#