HEARTLAND COMMUNITY HEALTH CLINIC (HEARTLAND DENTAL CLINIC ALLIED) - NPI NUMBER 1548201098

Summary

Provider Name: HEARTLAND COMMUNITY HEALTH CLINIC (HEARTLAND DENTAL CLINIC ALLIED)

NPI Number: 1548201098

Clasification: Clinic/Center (261QD0000X)

Specialization: Dental

Address:
2321 N WISCONSIN AVE
PEORIA, IL
ZIP 61603

Phone Number: (309) 680-7640



Detailed Information

HEARTLAND COMMUNITY HEALTH CLINIC is a dental clinic/center in Peoria, IL. The assigned NPI number for this provider is 1548201098 and is registered as an organization entity type.
The provider Is Doing Business As Heartland Dental Clinic Allied.

The provider's business address is:

2321 N WISCONSIN AVE
PEORIA, IL
ZIP 61603-613
Phone: (309) 680-7640
Fax: (309) 681-8601

The provider's authorized official is Farrell K Davies .
The authorized official title is Ceo and has the following contact phone number (309) 680-7657.

The enumeration date for this NPI number is 6/8/2006 and was last updated on 3/9/2010.

Map - Location of Practice

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Taxonomy Codes

The following information regarding the scope of practice of this provider is available:

No. Taxonomy Code Taxonomy Clasification Taxonomy Specialization License Number License State Primary
1 261QD0000X Clinic/Center Dental Yes

Other (Legacy) Identifiers

The following legacy identifiers are available for this provider:

No. Other Provider Identifier Other Provider Identifier Type Other Provider Identifier State Other Provider Identifier Issuer
1 =========005 MEDICAID IL

NPI Record

No. Field Name Field Value
1 NPI 1548201098
2 Entity Type Code 2
3 Employer Identification Number EIN
4 Provider Organization Name Legal Business Name HEARTLAND COMMUNITY HEALTH CLINIC
5 Provider Other Organization Name HEARTLAND DENTAL CLINIC ALLIED
6 Provider Other Organization Name Type Code 3
7 Provider First Line Business Practice Location Address 2321 N WISCONSIN AVE
8 Provider Business Practice Location Address City Name PEORIA
9 Provider Business Practice Location Address State Name IL
10 Provider Business Practice Location Address Postal Code 616035613
11 Provider Business Practice Location Address Country Code If outside U S US
12 Provider Business Practice Location Address Telephone Number 3096807640
13 Provider Business Practice Location Address Fax Number 3096818601
14 Provider Enumeration Date 6/8/2006
15 Last Update Date 3/9/2010
16 Authorized Official Last Name DAVIES
17 Authorized Official First Name FARRELL
18 Authorized Official Middle Name K
19 Authorized Official Title or Position CEO
20 Authorized Official Telephone Number 3096807657
21 Healthcare Provider Taxonomy Code 1 261QD0000X
22 Healthcare Provider Primary Taxonomy Switch 1 Y
23 Other Provider Identifier 1 =========005
24 Other Provider Identifier Type Code 1 05
25 Other Provider Identifier State 1 IL
26 Is Organization Subpart N
27 Authorized Official Name Prefix Text MS.

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This page was last updated on: 11/14/2014
All materials and services on this site are provided on an "as is" and "as available" basis without warranty of any kind. The NPI record is maintained by the National Plan & Provider Enumeration System (NPPES) and anyone may request this information and other NPPES health care provider data from HHS under The Freedom of Information Act (FOIA), Title 5 of the United States Code, section 552. To update the NPI records please contact the NPPES.