Provider Demographics
NPI:1215404819
Name:HEARTLAND BANYAN, LLC
Entity Type:Organization
Organization Name:HEARTLAND BANYAN, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF CREDENTIALING & CONTRAC
Authorized Official - Prefix:MR
Authorized Official - First Name:RENE
Authorized Official - Middle Name:
Authorized Official - Last Name:MOLINA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-533-7705
Mailing Address - Street 1:225 N FEDERAL HWY
Mailing Address - Street 2:
Mailing Address - City:POMPANO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33062-4319
Mailing Address - Country:US
Mailing Address - Phone:888-879-4975
Mailing Address - Fax:954-781-7173
Practice Address - Street 1:1237 E 1600 NORTH RD
Practice Address - Street 2:
Practice Address - City:GILMAN
Practice Address - State:IL
Practice Address - Zip Code:60938-6112
Practice Address - Country:US
Practice Address - Phone:888-879-4975
Practice Address - Fax:954-781-7173
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-01
Last Update Date:2023-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No283Q00000XHospitalsPsychiatric Hospital