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General NPI Number Information
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NPI Number | 1790942084
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Entity Type | Organization
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Legal Business Name | HEARTLAND INTERNATIONAL HEALTH CENTER
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Dates
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Enumeration Date | 05/22/2008
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Last Update Date | 09/20/2010
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Provider Practice Location Address
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Address Line | 845 W WILSON AVE
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City | CHICAGO
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State | IL
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Zip | 60640-5704
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Country | US
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Telephone | 773-728-7264
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Fax | 773-728-7557
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Provider Business Mailing Address
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Address Line | 3048 N. WILTON AVE 2ND FLOOR
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City | CHICAGO
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State | IL
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Zip | 60657-6710
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Country | US
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Telephone | 773-296-7544
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Fax | 773-751-4175
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | GWENN RAUSCH
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Credential |
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Telephone | 773-296-7589
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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 | 003
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License Number State | IL
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