Provider Demographics
NPI:1174007538
Name:HEARTLAND INFUSION
Entity Type:Organization
Organization Name:HEARTLAND INFUSION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:WALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:865-689-9778
Mailing Address - Street 1:9943 KINGSTON PIKE
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37922-6923
Mailing Address - Country:US
Mailing Address - Phone:865-862-4557
Mailing Address - Fax:
Practice Address - Street 1:9943 KINGSTON PIKE
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37922-6923
Practice Address - Country:US
Practice Address - Phone:865-862-4557
Practice Address - Fax:865-862-4556
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-21
Last Update Date:2021-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QI0500XAmbulatory Health Care FacilitiesClinic/CenterInfusion Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0575OtherLOCAL PART B
TN1534157Medicaid