Healthcare Provider Details

I. General information

NPI: 1811026461
Provider Name (Legal Business Name): HEARTLAND RESOURCES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 EAST MAIN STREET
EWING MO
63440-0460
US

IV. Provider business mailing address

108 EAST MAIN STREET
EWING MO
63440-0460
US

V. Phone/Fax

Practice location:
  • Phone: 573-209-3600
  • Fax: 573-209-3509
Mailing address:
  • Phone: 573-209-3600
  • Fax: 573-209-3509

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. VIRGIE TRAVELLE WHITAKER
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 573-209-3600