Provider Demographics
NPI:1760681472
Name:HETLAND, MIKE DUANE
Entity Type:Individual
Prefix:
First Name:MIKE
Middle Name:DUANE
Last Name:HETLAND
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 1:1301 YOSEMITE PKWY
Mailing Address - Street 2:
Mailing Address - City:MERCED
Mailing Address - State:CA
Mailing Address - Zip Code:95340-5203
Mailing Address - Country:US
Mailing Address - Phone:209-722-6335
Mailing Address - Fax:209-722-6371
Practice Address - Street 1:1301 YOSEMITE PKWY
Practice Address - Street 2:
Practice Address - City:MERCED
Practice Address - State:CA
Practice Address - Zip Code:95340-5203
Practice Address - Country:US
Practice Address - Phone:209-722-6335
Practice Address - Fax:209-722-6371
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-12
Last Update Date:2007-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility