Provider Demographics
NPI:1932499415
Name:HEARTLAND SUPPORTED LIVING INC.
Entity Type:Organization
Organization Name:HEARTLAND SUPPORTED LIVING INC.
Other - Org Name:HEARTLAND SUPPORTED LIVING INC.
Other - Org Type:Other Name
Authorized Official - Title/Position:CORPORATE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RON
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCORMICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-475-4108
Mailing Address - Street 1:223 N MAIN ST # 122
Mailing Address - Street 2:
Mailing Address - City:SIKESTON
Mailing Address - State:MO
Mailing Address - Zip Code:63801-4211
Mailing Address - Country:US
Mailing Address - Phone:573-475-4108
Mailing Address - Fax:573-475-4109
Practice Address - Street 1:205 N NEW MADRID ST
Practice Address - Street 2:
Practice Address - City:SIKESTON
Practice Address - State:MO
Practice Address - Zip Code:63801-4142
Practice Address - Country:US
Practice Address - Phone:573-475-4108
Practice Address - Fax:573-475-4109
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-18
Last Update Date:2015-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO320900000XMedicaid