Provider Demographics
NPI:1790942084
Name:HEARTLAND INTERNATIONAL HEALTH CENTER
Entity Type:Organization
Organization Name:HEARTLAND INTERNATIONAL HEALTH CENTER
Other - Org Name:HEARTLAND HEALTH CENTER-WILSON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GWENN
Authorized Official - Middle Name:
Authorized Official - Last Name:RAUSCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-296-7589
Mailing Address - Street 1:3048 N. WILTON AVE
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-6710
Mailing Address - Country:US
Mailing Address - Phone:773-296-7544
Mailing Address - Fax:773-751-4175
Practice Address - Street 1:845 W WILSON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-5704
Practice Address - Country:US
Practice Address - Phone:773-728-7264
Practice Address - Fax:773-728-7557
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-22
Last Update Date:2010-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL103527OtherDORAL DENTAL