Provider Demographics
NPI:1104989680
Name:HEARTLAND PEDIATRICS OF LAKE WALES, LLC
Entity type:Organization
Organization Name:HEARTLAND PEDIATRICS OF LAKE WALES, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LAURENCE
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:HREN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:863-676-1770
Mailing Address - Street 1:1354 STATE ROAD 60 E
Mailing Address - Street 2:
Mailing Address - City:LAKE WALES
Mailing Address - State:FL
Mailing Address - Zip Code:33853-4322
Mailing Address - Country:US
Mailing Address - Phone:863-679-8888
Mailing Address - Fax:863-676-2851
Practice Address - Street 1:1354 STATE ROAD 60 E
Practice Address - Street 2:
Practice Address - City:LAKE WALES
Practice Address - State:FL
Practice Address - Zip Code:33853-4322
Practice Address - Country:US
Practice Address - Phone:863-679-8888
Practice Address - Fax:863-676-2851
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2025-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL251469900Medicaid
FL21247OtherBLUE CROSS BLUE SHIELD
FL251469901Medicaid
FL21247OtherBLUE CROSS BLUE SHIELD