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General NPI Number Information
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NPI Number | 1720245491
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Entity Type | Organization
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Legal Business Name | HEARTLAND HEALTH OUTREACH
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Dates
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Enumeration Date | 05/20/2008
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Last Update Date | 05/20/2008
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Provider Practice Location Address
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Address Line | 641 W 63RD ST
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City | CHICAGO
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State | IL
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Zip | 60621-2032
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Country | US
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Telephone | 773-488-4277
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Fax | 773-488-4292
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Provider Business Mailing Address
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Address Line | 4750 N SHERIDAN RD #434
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City | CHICAGO
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State | IL
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Zip | 60640-7528
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Country | US
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Telephone | 773-751-1704
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Fax | 773-751-4175
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Authorized Official
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Title or Position | CONTROLLER
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Name | HEIDI NELSON
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Credential |
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Telephone | 773-751-4107
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 016
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License Number State | IL
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