Provider Demographics
NPI:1619134111
Name:HEARTLAND ALLIANCE HEALTH
Entity Type:Organization
Organization Name:HEARTLAND ALLIANCE HEALTH
Other - Org Name:HEARTLAND HEALTH OUTREACH
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DIRECTOR, REVENUE CYCLE MANAGEMENT
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:773-751-4129
Mailing Address - Street 1:4750 N SHERIDAN RD STE 449
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-5078
Mailing Address - Country:US
Mailing Address - Phone:773-751-4129
Mailing Address - Fax:773-751-4175
Practice Address - Street 1:1015 W LAWRENCE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-5017
Practice Address - Country:US
Practice Address - Phone:773-751-4129
Practice Address - Fax:773-751-4175
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-21
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL077560001261QR0405X, 101YA0400X, 261QR0405X
IL022101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use DisorderGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL022Medicaid