Provider Demographics
NPI:1013787217
Name:HEATLEY, ROGER SHAWN
Entity Type:Individual
Prefix:MR
First Name:ROGER
Middle Name:SHAWN
Last Name:HEATLEY
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 1:230 GENE ST
Mailing Address - Street 2:
Mailing Address - City:BAMBERG
Mailing Address - State:SC
Mailing Address - Zip Code:29003-8245
Mailing Address - Country:US
Mailing Address - Phone:404-285-0373
Mailing Address - Fax:
Practice Address - Street 1:230 GENE ST
Practice Address - Street 2:
Practice Address - City:BAMBERG
Practice Address - State:SC
Practice Address - Zip Code:29003-8245
Practice Address - Country:US
Practice Address - Phone:404-285-0373
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-08
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC007056172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver