Provider Demographics
NPI:1790976686
Name:HEARTLAND LABORATORY INC
Entity Type:Organization
Organization Name:HEARTLAND LABORATORY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PATHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:F
Authorized Official - Last Name:BLANK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:5738-873-6321
Mailing Address - Street 1:221 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CHAFFEE
Mailing Address - State:MO
Mailing Address - Zip Code:63740-1040
Mailing Address - Country:US
Mailing Address - Phone:573-887-3632
Mailing Address - Fax:573-887-3635
Practice Address - Street 1:221 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CHAFFEE
Practice Address - State:MO
Practice Address - Zip Code:63740-1040
Practice Address - Country:US
Practice Address - Phone:573-887-3632
Practice Address - Fax:573-887-3635
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-06
Last Update Date:2010-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO34699291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036081467OtherPATHOLOGY
MO207ZD0900X MOOtherPATHOLOGY
A10261Medicare UPIN