Basic Information
| Provider Information | |||||||||
| NPI: | 1194782920 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HETER | ||||||||
| FirstName: | KRISTIN | ||||||||
| MiddleName: | L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1200 CORPORATE DR STE 400 | ||||||||
| Address2: | |||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352425424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4236828840 | ||||||||
| FaxNumber: | 4236022028 | ||||||||
| Practice Location | |||||||||
| Address1: | 1424 HIGHWAY 17 N STE 2 | ||||||||
| Address2: | |||||||||
| City: | NORTH MYRTLE BEACH | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295822507 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8434277132 | ||||||||
| FaxNumber: | 8434277154 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2006 | ||||||||
| LastUpdateDate: | 11/20/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 32683 | CA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | P14185 | NC | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 9372 | SC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.