Provider Demographics
NPI:1083688030
Name:HEATON, BOB PHILLIP (DC)
Entity Type:Individual
Prefix:
First Name:BOB
Middle Name:PHILLIP
Last Name:HEATON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1320 S. AMMON ROAD
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83406-5810
Mailing Address - Country:US
Mailing Address - Phone:208-529-2084
Mailing Address - Fax:208-529-2084
Practice Address - Street 1:1320 S AMMON ROAD
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83406-5810
Practice Address - Country:US
Practice Address - Phone:208-529-2084
Practice Address - Fax:208-529-2084
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-15
Last Update Date:2014-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA 369111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000953900Medicaid
000010008077OtherBLUE CROSS BLUE SHIELD
1671065Medicare ID - Type Unspecified