Basic Information
| Provider Information | |||||||||
| NPI: | 1245470376 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | OLE A. HEGGENESS, D.O., INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 21015 PATHFINDER RD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | DIAMOND BAR | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917654018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9098613511 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 21015 PATHFINDER RD | ||||||||
| Address2: | 100 | ||||||||
| City: | DIAMOND BAR | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917654018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9098613511 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2009 | ||||||||
| LastUpdateDate: | 03/02/2009 | ||||||||
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| AuthorizedOfficialLastName: | HEGGENESS | ||||||||
| AuthorizedOfficialFirstName: | OLE | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9094553369 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | D.O. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | 20A4925 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center |
No ID Information.