Provider Demographics
NPI:1467504704
Name:HEISNER, TERRY GLEN (DC)
Entity Type:Individual
Prefix:MR
First Name:TERRY
Middle Name:GLEN
Last Name:HEISNER
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 1:806 JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42001-6820
Mailing Address - Country:US
Mailing Address - Phone:270-443-4988
Mailing Address - Fax:270-443-4988
Practice Address - Street 1:806 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42001-6820
Practice Address - Country:US
Practice Address - Phone:270-443-4988
Practice Address - Fax:270-443-4988
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3651R111N00000X
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILHE715490OtherMEDICARE
KY6011801Medicare ID - Type Unspecified
T38060Medicare UPIN