Provider Demographics
NPI:1376896431
Name:HEAVERLO, ANTHONY CARL (DC)
Entity Type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:CARL
Last Name:HEAVERLO
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 1:16670 FRANKLIN TRL SE
Mailing Address - Street 2:
Mailing Address - City:PRIOR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55372-2924
Mailing Address - Country:US
Mailing Address - Phone:952-447-5770
Mailing Address - Fax:952-447-5780
Practice Address - Street 1:16670 FRANKLIN TRL SE
Practice Address - Street 2:
Practice Address - City:PRIOR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55372-2924
Practice Address - Country:US
Practice Address - Phone:952-447-5770
Practice Address - Fax:952-447-5780
Is Sole Proprietor?:No
Enumeration Date:2012-10-25
Last Update Date:2012-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5704111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor