Provider Demographics
NPI:1972088615
Name:HEARTLAND INTERNATIONAL HEALTH CENTER
Entity Type:Organization
Organization Name:HEARTLAND INTERNATIONAL HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:HUELL
Authorized Official - Middle Name:LYLE
Authorized Official - Last Name:COLLIER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-296-7544
Mailing Address - Street 1:3048 N WILTON AVE FL 2
Mailing Address - Street 2:
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:773-296-7637
Practice Address - Street 1:3048 N WILTON AVE FL 2
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-6710
Practice Address - Country:US
Practice Address - Phone:773-296-7544
Practice Address - Fax:773-296-7637
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-28
Last Update Date:2018-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL63843377001Medicaid