Provider Demographics
NPI:1043465321
Name:HEARTLAND HEALTH LLC
Entity type:Organization
Organization Name:HEARTLAND HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:LYLE
Authorized Official - Last Name:POLSFUSS
Authorized Official - Suffix:
Authorized Official - Credentials:MA, MSW
Authorized Official - Phone:952-922-9056
Mailing Address - Street 1:15552 DYNASTY WAY
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55124-7836
Mailing Address - Country:US
Mailing Address - Phone:952-922-9056
Mailing Address - Fax:
Practice Address - Street 1:6950 FRANCE AVE S STE 14
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-2016
Practice Address - Country:US
Practice Address - Phone:952-922-9056
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-30
Last Update Date:2008-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP0620251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN013848700Medicaid
MN800000143Medicare PIN
MN013848700Medicaid