Healthcare Provider Details

I. General information

NPI: 1619134111
Provider Name (Legal Business Name): HEARTLAND ALLIANCE HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2008
Last Update Date: 11/17/2020
Certification Date: 11/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1015 W LAWRENCE AVE
CHICAGO IL
60640-5017
US

IV. Provider business mailing address

4750 N SHERIDAN RD STE 449
CHICAGO IL
60640-5078
US

V. Phone/Fax

Practice location:
  • Phone: 773-751-4129
  • Fax: 773-751-4175
Mailing address:
  • Phone: 773-751-4129
  • Fax: 773-751-4175

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number077560001
License Number StateIL

VIII. Authorized Official

Name: JIMMY VALENTIN
Title or Position: DIRECTOR, REVENUE CYCLE MANAGEMENT
Credential:
Phone: 773-751-4129