Provider Demographics
NPI:1811551211
Name:HEART CITY HEALTH CENTER, INC.
Entity Type:Organization
Organization Name:HEART CITY HEALTH CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ESLEEN
Authorized Official - Middle Name:E
Authorized Official - Last Name:FULTZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:574-970-3257
Mailing Address - Street 1:236 SIMPSON AVE
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46516-4666
Mailing Address - Country:US
Mailing Address - Phone:574-584-7373
Mailing Address - Fax:574-293-1739
Practice Address - Street 1:2100 SUPERIOR ST
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46516-4704
Practice Address - Country:US
Practice Address - Phone:574-970-1937
Practice Address - Fax:574-970-1939
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HEART CITY HEALTH CENTER, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-05-01
Last Update Date:2019-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
INPENDINGMedicaid