1154364909 NPI number — HEARTLAND OF AUSTIN TX LLC

Table of content: (NPI 1154364909)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154364909 NPI number — HEARTLAND OF AUSTIN TX LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HEARTLAND OF AUSTIN TX 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:
1154364909
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/30/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
333 N SUMMIT ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TOLEDO
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43604-2615
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
419-252-5500
Provider Business Mailing Address Fax Number:
877-385-9446

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11406 RUSTIC ROCK DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AUSTIN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78750-3505
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
512-335-5028
Provider Business Practice Location Address Fax Number:
512-335-0709
Provider Enumeration Date:
06/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ALLEN
Authorized Official First Name:
MARTIN
Authorized Official Middle Name:
D
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
419-252-5734

Provider Taxonomy Codes

  • Taxonomy code: 310400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 314000000X , with the licence number: 112897 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 001015387 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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