Provider Demographics
NPI:1720353709
Name:HEITHOLT, MICHAEL (DC)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:HEITHOLT
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 1:14297 BERGEN BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:NOBLESVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46060-3382
Mailing Address - Country:US
Mailing Address - Phone:317-674-8800
Mailing Address - Fax:
Practice Address - Street 1:14297 BERGEN BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:NOBLESVILLE
Practice Address - State:IN
Practice Address - Zip Code:46060-3382
Practice Address - Country:US
Practice Address - Phone:317-674-8800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-09
Last Update Date:2016-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038012321111NR0400X
IN08002642A111N00000X, 111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitation
No111N00000XChiropractic ProvidersChiropractor