Healthcare Provider Details

I. General information

NPI: 1972088615
Provider Name (Legal Business Name): HEARTLAND INTERNATIONAL HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2018
Last Update Date: 09/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3048 N WILTON AVE FL 2
CHICAGO IL
60657-6710
US

IV. Provider business mailing address

3048 N WILTON AVE FL 2
CHICAGO IL
60657-6710
US

V. Phone/Fax

Practice location:
  • Phone: 773-296-7544
  • Fax: 773-296-7637
Mailing address:
  • Phone: 773-296-7544
  • Fax: 773-296-7637

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State

VIII. Authorized Official

Name: HUELL LYLE COLLIER
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 773-296-7544