Healthcare Provider Details

I. General information

NPI: 1790942084
Provider Name (Legal Business Name): HEARTLAND INTERNATIONAL HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2008
Last Update Date: 09/20/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

845 W WILSON AVE
CHICAGO IL
60640-5704
US

IV. Provider business mailing address

3048 N. WILTON AVE 2ND FLOOR
CHICAGO IL
60657-6710
US

V. Phone/Fax

Practice location:
  • Phone: 773-728-7264
  • Fax: 773-728-7557
Mailing address:
  • Phone: 773-296-7544
  • Fax: 773-751-4175

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number003
License Number StateIL

VIII. Authorized Official

Name: GWENN RAUSCH
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 773-296-7589