Basic Information
| Provider Information | |||||||||
| NPI: | 1184676074 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HEARTLAND HOME CARE LLC | ||||||||
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| OtherOrganizationName: | PROMEDICA HOME HEALTH (FT. WAYNE) | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 333 N SUMMIT ST | ||||||||
| Address2: | ATTN: DEAN SHIPMAN | ||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436041531 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192547841 | ||||||||
| FaxNumber: | 4192526448 | ||||||||
| Practice Location | |||||||||
| Address1: | 1315 DIRECTORS ROW | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | FT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468081284 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2169011464 | ||||||||
| FaxNumber: | 2169860081 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 01/23/2022 | ||||||||
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| AuthorizedOfficialLastName: | LAZARUS | ||||||||
| AuthorizedOfficialFirstName: | BARRY | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT - REIMBURSEMENTS | ||||||||
| AuthorizedOfficialTelephone: | 4192525541 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 01/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251F00000X | N | Agencies | Home Infusion | 251E00000X | 05-005366-1 | IN | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 100265250 | 05 | IN | MEDICAID |