Provider Demographics
NPI:1164520623
Name:HELLER, FRED DANA (DC)
Entity Type:Individual
Prefix:
First Name:FRED
Middle Name:DANA
Last Name:HELLER
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 1:517 CALDWELL AVE
Mailing Address - Street 2:
Mailing Address - City:OCONTO FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54154-1139
Mailing Address - Country:US
Mailing Address - Phone:920-846-3778
Mailing Address - Fax:920-846-3877
Practice Address - Street 1:517 CALDWELL AVE
Practice Address - Street 2:
Practice Address - City:OCONTO FALLS
Practice Address - State:WI
Practice Address - Zip Code:54154-1139
Practice Address - Country:US
Practice Address - Phone:920-846-3778
Practice Address - Fax:920-846-3877
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2012-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3043-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38904000Medicaid
WI000043120Medicare PIN
WIU48615Medicare UPIN
WI38904000Medicaid