Provider Demographics
NPI:1053185934
Name:HEINTZ, THEODORE
Entity type:Individual
Prefix:
First Name:THEODORE
Middle Name:
Last Name:HEINTZ
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 1:511 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:WV
Mailing Address - Zip Code:26554-5242
Mailing Address - Country:US
Mailing Address - Phone:502-424-7291
Mailing Address - Fax:
Practice Address - Street 1:511 MARKET ST
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:WV
Practice Address - Zip Code:26554-5242
Practice Address - Country:US
Practice Address - Phone:502-424-7291
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-10
Last Update Date:2023-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker