Provider Demographics
NPI:1760838775
Name:HEITZ, KODY JOHN-EVERETT
Entity Type:Individual
Prefix:
First Name:KODY
Middle Name:JOHN-EVERETT
Last Name:HEITZ
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 1:35640 W MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:MI
Mailing Address - Zip Code:48184-1628
Mailing Address - Country:US
Mailing Address - Phone:419-203-0578
Mailing Address - Fax:
Practice Address - Street 1:35640 W MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:MI
Practice Address - Zip Code:48184-1628
Practice Address - Country:US
Practice Address - Phone:419-203-0578
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-09
Last Update Date:2016-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other