Provider Demographics
NPI:1295130029
Name:FENTZKE, HEIDI (DC)
Entity type:Individual
Prefix:DR
First Name:HEIDI
Middle Name:
Last Name:FENTZKE
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 GALLOWAY TER
Mailing Address - Street 2:
Mailing Address - City:KINNELON
Mailing Address - State:NJ
Mailing Address - Zip Code:07405-3214
Mailing Address - Country:US
Mailing Address - Phone:973-838-8399
Mailing Address - Fax:
Practice Address - Street 1:6000 KENNEDY BLVD W
Practice Address - Street 2:
Practice Address - City:WEST NEW YORK
Practice Address - State:NJ
Practice Address - Zip Code:07093-1414
Practice Address - Country:US
Practice Address - Phone:973-838-8399
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-22
Last Update Date:2016-09-01
Deactivation Date:2015-07-29
Deactivation Code:
Reactivation Date:2016-09-01
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00476000111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor