Provider Demographics
NPI:1790026409
Name:HEASTY, RODERICK M (DC)
Entity Type:Individual
Prefix:
First Name:RODERICK
Middle Name:M
Last Name:HEASTY
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 1:3252 KIMBALL AVE
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN
Mailing Address - State:KS
Mailing Address - Zip Code:66503-2157
Mailing Address - Country:US
Mailing Address - Phone:785-320-6868
Mailing Address - Fax:
Practice Address - Street 1:3252 KIMBALL AVE
Practice Address - Street 2:
Practice Address - City:MANHATTAN
Practice Address - State:KS
Practice Address - Zip Code:66503-2157
Practice Address - Country:US
Practice Address - Phone:785-320-6868
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-05
Last Update Date:2013-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS01-05525111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor