Provider Demographics
NPI:1639367501
Name:HEATHERLY, WESLEY F (DC)
Entity Type:Individual
Prefix:
First Name:WESLEY
Middle Name:F
Last Name:HEATHERLY
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 1:1355 E CENTER ST
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-4737
Mailing Address - Country:US
Mailing Address - Phone:208-238-9355
Mailing Address - Fax:208-233-1200
Practice Address - Street 1:1355 E CENTER ST
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4737
Practice Address - Country:US
Practice Address - Phone:208-238-9355
Practice Address - Fax:208-233-1200
Is Sole Proprietor?:No
Enumeration Date:2007-10-04
Last Update Date:2007-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA-1258111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor