MEDICARE: HEALTHE LAND

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084N0400X	Neurology Physician		IL

General Provider Information

NPI Number	:	1013039866
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HEALTHE LAND

Provider Business Mailing Address
First Line	:	4022 W 21ST PL
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60623-2829
Country	:	US
Telephone Number	:	773-699-7630
Fax Number	:	773-751-2250

Provider Business Practice Location Address
First Line	:	4022 W 21ST PL
Second Line	:	2ND FLOOR
City	:	CHICAGO
State	:	IL
Zip	:	60623-2829
Country	:	US
Telephone Number	:	773-699-7630
Fax Number	:	773-751-2250

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. ETTA GUEST
Credential	:	PHD
Telephone Number	:	773-699-7630

Provider Enumeration Date	:	04/04/2007
Last Update Date	:	08/22/2020

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Directions to “HEALTHE LAND ” Practice Location

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