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General NPI Number Information
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NPI Number | 1932499415
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Entity Type | Organization
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Legal Business Name | HEARTLAND SUPPORTED LIVING INC.
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Dates
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Enumeration Date | 04/18/2011
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Last Update Date | 07/09/2015
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Provider Practice Location Address
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Address Line | 205 N NEW MADRID ST
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City | SIKESTON
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State | MO
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Zip | 63801-4142
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Country | US
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Telephone | 573-475-4108
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Fax | 573-475-4109
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Provider Business Mailing Address
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Address Line | 223 N MAIN ST # 122
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City | SIKESTON
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State | MO
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Zip | 63801-4211
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Country | US
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Telephone | 573-475-4108
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Fax | 573-475-4109
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Authorized Official
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Title or Position | CORPORATE PRESIDENT
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Name | MR. RON MCCORMICK
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Credential |
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Telephone | 573-475-4108
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 253Z00000X
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Taxonomy Name | In Home Supportive Care Agency
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License Number |
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License Number State | MO
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