Provider Demographics
NPI:1902343056
Name:HEATHCOCK, DALE
Entity Type:Individual
Prefix:MR
First Name:DALE
Middle Name:
Last Name:HEATHCOCK
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 1:2502 PLATINUM CHASE DR
Mailing Address - Street 2:
Mailing Address - City:ROSHARON
Mailing Address - State:TX
Mailing Address - Zip Code:77583-3275
Mailing Address - Country:US
Mailing Address - Phone:281-635-7458
Mailing Address - Fax:281-778-5114
Practice Address - Street 1:107 W WAY ST
Practice Address - Street 2:SUITE 19-20
Practice Address - City:LAKE JACKSON
Practice Address - State:TX
Practice Address - Zip Code:77566-5219
Practice Address - Country:US
Practice Address - Phone:979-266-9497
Practice Address - Fax:979-266-9507
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-27
Last Update Date:2017-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1200XAmbulatory Health Care FacilitiesClinic/CenterSleep Disorder Diagnostic