Provider Demographics
NPI:1104024868
Name:CHILDS, HEIDI RAQUEL
Entity Type:Individual
Prefix:MISS
First Name:HEIDI
Middle Name:RAQUEL
Last Name:CHILDS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29903 SUNNY BEACH RD
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55744-4528
Mailing Address - Country:US
Mailing Address - Phone:218-326-1485
Mailing Address - Fax:
Practice Address - Street 1:29903 SUNNY BEACH RD
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55744-4528
Practice Address - Country:US
Practice Address - Phone:218-326-1485
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider