Provider Demographics
NPI:1538134440
Name:HEISNER, MONTY CARL (DC)
Entity Type:Individual
Prefix:
First Name:MONTY
Middle Name:CARL
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 1:5649 BENTON ROAD
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42003
Mailing Address - Country:US
Mailing Address - Phone:270-898-3052
Mailing Address - Fax:270-898-3052
Practice Address - Street 1:5649 BENTON ROAD
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003
Practice Address - Country:US
Practice Address - Phone:270-898-3052
Practice Address - Fax:270-898-3052
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3493R111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY85002046Medicaid
KY000000047805OtherANTHEM
KY000000047805OtherANTHEM
KY6012201Medicare ID - Type Unspecified