Provider Demographics
NPI:1538294483
Name:HEARTLAND ALLIANCE HEALTH
Entity Type:Organization
Organization Name:HEARTLAND ALLIANCE HEALTH
Other - Org Name:HEARTLAND HEALTH OUTREACH, INC.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:SR. DIRECTOR, HEALTH INFORMATION SY
Authorized Official - Prefix:
Authorized Official - First Name:JIMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:VALENTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-220-8562
Mailing Address - Street 1:4009 N BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-2110
Mailing Address - Country:US
Mailing Address - Phone:773-275-2586
Mailing Address - Fax:773-751-4175
Practice Address - Street 1:4009 N BROADWAY ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613-2110
Practice Address - Country:US
Practice Address - Phone:773-275-2586
Practice Address - Fax:773-751-4175
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL251B00000X, 251S00000X, 261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========OtherEIN
IL141842Medicare ID - Type UnspecifiedPROVIDER NUMBER