Provider Demographics
NPI:1639664543
Name:HEINTZELMAN, JOHN EUGENE
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:EUGENE
Last Name:HEINTZELMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:777 N RAINBOW BLVD STE 360
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89107-1188
Mailing Address - Country:US
Mailing Address - Phone:702-947-4474
Mailing Address - Fax:702-978-6215
Practice Address - Street 1:777 N RAINBOW BLVD STE 360
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89107-1188
Practice Address - Country:US
Practice Address - Phone:702-947-4474
Practice Address - Fax:702-978-6215
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-25
Last Update Date:2018-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator