Provider Demographics
NPI:1548510456
Name:HEARTLAND MEDIVAN
Entity type:Organization
Organization Name:HEARTLAND MEDIVAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:TIM
Authorized Official - Middle Name:D
Authorized Official - Last Name:NIKKEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:1065-205-0061
Mailing Address - Street 1:P.O. BOX 374
Mailing Address - Street 2:
Mailing Address - City:VERMILLION
Mailing Address - State:SD
Mailing Address - Zip Code:57069
Mailing Address - Country:US
Mailing Address - Phone:605-205-0061
Mailing Address - Fax:
Practice Address - Street 1:31566 469TH AVE
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:SD
Practice Address - Zip Code:57010-7028
Practice Address - Country:US
Practice Address - Phone:605-205-0061
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-18
Last Update Date:2012-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)