1013277979 NPI number — HEARTLAND TRAVEL HEALTH SERVICES LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013277979 NPI number — HEARTLAND TRAVEL HEALTH SERVICES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HEARTLAND TRAVEL HEALTH SERVICES LLC
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:
1013277979
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/23/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3545 NW 58TH ST
Provider Second Line Business Mailing Address:
SUIT 340
Provider Business Mailing Address City Name:
OKLAHOMA CITY
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73112-4726
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
888-528-9521
Provider Business Mailing Address Fax Number:
888-521-6702

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3545 NW 58TH ST
Provider Second Line Business Practice Location Address:
SUIT 340
Provider Business Practice Location Address City Name:
OKLAHOMA CITY
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73112-4726
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
888-528-9521
Provider Business Practice Location Address Fax Number:
888-521-6702
Provider Enumeration Date:
05/24/2012

Additional Information

Authorized Official

Authorized Official Last Name:
HAYMORE
Authorized Official First Name:
BRET
Authorized Official Middle Name:
RICE
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
405-563-8961

Provider Taxonomy Codes

  • Taxonomy code: 302R00000X , with the licence number:  28286 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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