Provider Demographics
NPI:1811740939
Name:HEATER, BRADLEY RUSSELL
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:RUSSELL
Last Name:HEATER
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 1:100 SHORT ST
Mailing Address - Street 2:
Mailing Address - City:LOUISA
Mailing Address - State:KY
Mailing Address - Zip Code:41230-1275
Mailing Address - Country:US
Mailing Address - Phone:502-705-4891
Mailing Address - Fax:
Practice Address - Street 1:502 N LACKEY AVE
Practice Address - Street 2:
Practice Address - City:LOUISA
Practice Address - State:KY
Practice Address - Zip Code:41230-1206
Practice Address - Country:US
Practice Address - Phone:606-483-1990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-09
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist