1881860245 NPI number — HEARTLAND HEALTH OUTREACH

Table of content: SHANE COREY SLUKA PA (NPI 1114454394)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881860245 NPI number — HEARTLAND HEALTH OUTREACH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HEARTLAND HEALTH OUTREACH
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1881860245
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4750 N SHERIDAN RD
Provider Second Line Business Mailing Address:
SUITE 434
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60640-7528
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
773-751-1704
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
845 W WILSON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60640-5704
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-728-7264
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/06/2008

Additional Information

Authorized Official

Authorized Official Last Name:
NELSON
Authorized Official First Name:
HEIDI
Authorized Official Middle Name:
Authorized Official Title or Position:
CONTROLLER
Authorized Official Telephone Number:
773-751-4107

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  014 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 103349 . This is a "DORAL DENTAL" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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