Healthcare Provider Details

I. General information

NPI: 1538294483
Provider Name (Legal Business Name): HEARTLAND ALLIANCE HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/22/2007
Last Update Date: 04/01/2024
Certification Date: 04/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4009 N BROADWAY ST
CHICAGO IL
60613-2110
US

IV. Provider business mailing address

4009 N BROADWAY ST
CHICAGO IL
60613-2110
US

V. Phone/Fax

Practice location:
  • Phone: 773-275-2586
  • Fax: 773-751-4175
Mailing address:
  • Phone: 773-275-2586
  • Fax: 773-751-4175

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number StateIL

VIII. Authorized Official

Name: JIMMY VALENTIN
Title or Position: SR. DIRECTOR, HEALTH INFORMATION SY
Credential:
Phone: 773-220-8562