Provider Demographics
NPI:1972635308
Name:HEARTLAND INDEPENDENT LIVING CENTER
Entity type:Organization
Organization Name:HEARTLAND INDEPENDENT LIVING CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:CHAMBERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-437-5100
Mailing Address - Street 1:1010 HWY 28
Mailing Address - Street 2:
Mailing Address - City:OWENSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:65066-1677
Mailing Address - Country:US
Mailing Address - Phone:573-437-5100
Mailing Address - Fax:573-437-5117
Practice Address - Street 1:1010 HWY 28
Practice Address - Street 2:
Practice Address - City:OWENSVILLE
Practice Address - State:MO
Practice Address - Zip Code:65066-1677
Practice Address - Country:US
Practice Address - Phone:573-437-5100
Practice Address - Fax:573-437-5117
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HEARTLAND INDEPENDENT LIVING CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-12
Last Update Date:2011-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251X00000XAgenciesSupports Brokerage
No253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO266212604Medicaid