Provider Demographics
NPI:1508080805
Name:HEITHAUS, PEGGY ANN (DC)
Entity Type:Individual
Prefix:DR
First Name:PEGGY
Middle Name:ANN
Last Name:HEITHAUS
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11411 S FORTUNA RD
Mailing Address - Street 2:STE 102
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85367-5678
Mailing Address - Country:US
Mailing Address - Phone:928-305-1010
Mailing Address - Fax:928-305-1009
Practice Address - Street 1:11411 S FORTUNA RD
Practice Address - Street 2:STE 102
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85367-5678
Practice Address - Country:US
Practice Address - Phone:928-305-1010
Practice Address - Fax:928-305-1009
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAZ4680111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZU16770Medicare UPIN
AZZDC4680AMedicare ID - Type Unspecified