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

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 Field Definition 1
1 NPI 1548201098 The 10-position all-numeric identification number assigned by the NPS to uniquely identify a health care provider. The NPI number includes an ISO standard check-digit in the 10th position. There is no intelligence about the health care provider in the number.
2 Entity Type Code 2 Code describing the type of health care provider that is being assigned an NPI. Codes are 1 = (Person): individual human being who furnishes health care; 2 = (Non-person): entity other than an individual human being that furnishes health care (for example, hospital, SNF, hospital subunit, pharmacy, or HMO).
3 Employer Identification Number EIN The Employer Identification Number (EIN), assigned by the IRS, of the provider being identified.
4 Provider Organization Name Legal Business Name HEARTLAND COMMUNITY HEALTH CLINIC The name of the organization provider. If the provider is an organization, this is the legal business name.
5 Provider Other Organization Name HEARTLAND DENTAL CLINIC ALLIED Other name by which the organization provider is or has been known.
6 Provider Other Organization Name Type Code 3 Code identifying the type of other name. Codes are: 1 = former name; 2 = professional name; 3 = doing business as (d/b/ a) name; 4 = former legal business name; 5 = other.
7 Provider First Line Business Practice Location Address 2321 N WISCONSIN AVE The first line location address of the provider being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box.
8 Provider Business Practice Location Address City Name PEORIA The city name in the location address of the provider being identified.
9 Provider Business Practice Location Address State Name IL The State code in the location of the provider being identified.
10 Provider Business Practice Location Address Postal Code 616035613 The postal ZIP or zone code in the location address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available.
11 Provider Business Practice Location Address Country Code If outside U S US The country code in the location address of the provider being identified.
12 Provider Business Practice Location Address Telephone Number 3096807640 The telephone number associated with the location address of the provider being identified.
13 Provider Business Practice Location Address Fax Number 3096818601 The fax number associated with the location address of the provider being identified.
14 Provider Enumeration Date 6/8/2006
15 Last Update Date 3/9/2010
16 Authorized Official Last Name DAVIES The last name of the person authorized to submit the NPI application or to change NPS data for a health care provider.
17 Authorized Official First Name FARRELL The first name of the authorized official.
18 Authorized Official Middle Name K The middle name of the authorized official.
19 Authorized Official Title or Position CEO The title or position of the authorized official.
20 Authorized Official Telephone Number 3096807657 The 10-position telephone number of the authorized official.
21 Healthcare Provider Taxonomy Code 1 261QD0000X Code designating the provider type, classification, and specialization. Codes are from the Healthcare Provider Taxonomy code list. The NPS will associate these data with the license data for providers with Entity type code = 1.
22 Healthcare Provider Primary Taxonomy Switch 1 Y
23 Other Provider Identifier 1 =========005 Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form.
24 Other Provider Identifier Type Code 1 05 Code indicating the type of identifier currently or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form.
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: 4/19/2015

(1) Field Definition Source-. Federal Register / Vol. 69, No. 15 / Friday, January 23, 2004 / Rules and Regulations - Part II Department of Health and Human Services Office of the Secretary 45 CFR Part 162 HIPAA Administrative Simplification: Standard Unique Health Identifier for Health Care Providers; Final Rule

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