Healthcare Provider Details

I. General information

NPI: 1063647311
Provider Name (Legal Business Name): HEARTLAND FAMILY SERVICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2009
Last Update Date: 08/31/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1722 AVE C
COUNCIL BLUFFS IA
51501-2440
US

IV. Provider business mailing address

2101 S 42ND ST
OMAHA NE
68105-2947
US

V. Phone/Fax

Practice location:
  • Phone: 712-435-5380
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: JOHN JEANETTA
Title or Position: PRESIDENT / CEO
Credential:
Phone: 402-552-7402