Healthcare Provider Details

I. General information

NPI: 1538548391
Provider Name (Legal Business Name): HEARTLAND THERAPEUTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2015
Last Update Date: 05/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8658 N MAIN ST
DAYTON OH
45415-1328
US

IV. Provider business mailing address

8658 N MAIN ST
DAYTON OH
45415-1328
US

V. Phone/Fax

Practice location:
  • Phone: 937-701-0030
  • Fax: 937-387-9043
Mailing address:
  • Phone: 937-701-0030
  • Fax: 937-387-9043

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number35051593
License Number StateOH

VIII. Authorized Official

Name: ABDULLAHI ISA MUBARAK
Title or Position: OWNER
Credential: M.D.
Phone: 937-701-0030