Provider Demographics
NPI:1013039866
Name:HEALTHE LAND
Entity Type:Organization
Organization Name:HEALTHE LAND
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ETTA
Authorized Official - Middle Name:
Authorized Official - Last Name:GUEST
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:773-699-7630
Mailing Address - Street 1:4022 W 21ST PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60623-2829
Mailing Address - Country:US
Mailing Address - Phone:773-699-7630
Mailing Address - Fax:773-751-2250
Practice Address - Street 1:4022 W 21ST PL
Practice Address - Street 2:2ND FLOOR
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60623-2829
Practice Address - Country:US
Practice Address - Phone:773-699-7630
Practice Address - Fax:773-751-2250
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty