1043293087 NPI number — HERITAGE HOME HEALTH LLC

Table of content: (NPI 1043293087)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043293087 NPI number — HERITAGE HOME HEALTH LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HERITAGE HOME HEALTH LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
CHOICE HOMECARE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1043293087
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/18/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6760 OLD JACKSONVILLE HWY
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
TYLER
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75703-0572
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-561-7250
Provider Business Mailing Address Fax Number:
903-561-7424

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1605 JUDSON RD
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
LONGVIEW
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75601-3662
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-561-7250
Provider Business Practice Location Address Fax Number:
903-561-7424
Provider Enumeration Date:
11/23/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
LANIER
Authorized Official First Name:
TRINA
Authorized Official Middle Name:
DAWN
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
903-932-1852

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  003340 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 677220 . This is a "MEDICARE TPN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: KO6772209 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".