Provider Demographics
NPI:1558997742
Name:HEART SHOP, LLC
Entity Type:Organization
Organization Name:HEART SHOP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:ROTHROCK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:928-708-9355
Mailing Address - Street 1:242 WHIPPLE ST
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86301-1787
Mailing Address - Country:US
Mailing Address - Phone:928-708-9355
Mailing Address - Fax:928-778-0278
Practice Address - Street 1:242 WHIPPLE ST
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-1787
Practice Address - Country:US
Practice Address - Phone:928-708-9355
Practice Address - Fax:928-778-0278
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-19
Last Update Date:2020-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty