Basic Information
| Provider Information | |||||||||
| NPI: | 1013039866 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HEALTHE LAND | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4022 W 21ST PL | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606232829 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7736997630 | ||||||||
| FaxNumber: | 7737512250 | ||||||||
| Practice Location | |||||||||
| Address1: | 4022 W 21ST PL | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606232829 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7736997630 | ||||||||
| FaxNumber: | 7737512250 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | GUEST | ||||||||
| AuthorizedOfficialFirstName: | ETTA | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7736997630 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | PHD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
No ID Information.