Provider Demographics
NPI:1104572460
Name:HEARTLAND LLC
Entity type:Organization
Organization Name:HEARTLAND LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:KENT
Authorized Official - Last Name:PAXSTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-536-3503
Mailing Address - Street 1:10156 N FARM ROAD 165
Mailing Address - Street 2:
Mailing Address - City:FAIR GROVE
Mailing Address - State:MO
Mailing Address - Zip Code:65648-8019
Mailing Address - Country:US
Mailing Address - Phone:417-536-3503
Mailing Address - Fax:
Practice Address - Street 1:10156 N FARM ROAD 165
Practice Address - Street 2:
Practice Address - City:FAIR GROVE
Practice Address - State:MO
Practice Address - Zip Code:65648-8019
Practice Address - Country:US
Practice Address - Phone:417-536-3503
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-25
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date: