Basic Information
| Provider Information | |||||||||
| NPI: | 1700839164 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HEARTLAND HOME CARE LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PROMEDICA HOME HEALTH (GRAND RAPIDS) | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 333 N SUMMIT ST | ||||||||
| Address2: | ATTN: DEAN SHIPMAN | ||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436042615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192547841 | ||||||||
| FaxNumber: | 4192526448 | ||||||||
| Practice Location | |||||||||
| Address1: | 3230 EAGLE PARK DR NE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495257047 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6169427733 | ||||||||
| FaxNumber: | 6169427870 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2006 | ||||||||
| LastUpdateDate: | 01/23/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ALLEN | ||||||||
| AuthorizedOfficialFirstName: | MARTIN | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4192525734 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 1451573 | 05 | MI | MEDICAID |