Healthcare Provider Details

I. General information

NPI: 1215404819
Provider Name (Legal Business Name): HEARTLAND BANYAN, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2018
Last Update Date: 04/15/2026
Certification Date: 04/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1237 E 1600 NORTH RD
GILMAN IL
60938-6112
US

IV. Provider business mailing address

225 N FEDERAL HWY
POMPANO BEACH FL
33062-4319
US

V. Phone/Fax

Practice location:
  • Phone: 815-707-2136
  • Fax: 815-707-0241
Mailing address:
  • Phone: 954-533-7705
  • Fax: 954-781-7173

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code283Q00000X
TaxonomyPsychiatric Hospital
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: JOHN SORY
Title or Position: CEO
Credential:
Phone: 954-533-7705