Provider Demographics
NPI:1962837690
Name:HEASLIP, CHRISTOPHER
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:
Last Name:HEASLIP
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 1:23160 FASHION DR
Mailing Address - Street 2:STE 217
Mailing Address - City:ESTERO
Mailing Address - State:FL
Mailing Address - Zip Code:33928-2559
Mailing Address - Country:US
Mailing Address - Phone:239-676-2304
Mailing Address - Fax:239-676-2344
Practice Address - Street 1:23160 FASHION DR
Practice Address - Street 2:STE 217
Practice Address - City:ESTERO
Practice Address - State:FL
Practice Address - Zip Code:33928-2559
Practice Address - Country:US
Practice Address - Phone:239-676-2304
Practice Address - Fax:239-676-2344
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-12
Last Update Date:2013-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLA114970171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLA114970OtherFLORIDA DEPARTMENT OF FINANCIAL SERVICES