Provider Demographics
NPI:1215258116
Name:HEARTLAND INTERNATIONAL HEALTH CENTER
Entity type:Organization
Organization Name:HEARTLAND INTERNATIONAL HEALTH CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GWENN
Authorized Official - Middle Name:
Authorized Official - Last Name:RAUSCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-296-7589
Mailing Address - Street 1:3048 N WILTON AVE
Mailing Address - Street 2:2ND FLOOR
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:
Practice Address - Street 1:4740 N CLARK ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-4689
Practice Address - Country:US
Practice Address - Phone:773-751-1700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-15
Last Update Date:2010-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019027796122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty