1225035058 NPI number — HERITAGE CARE INC

Table of content: (NPI 1225035058)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225035058 NPI number — HERITAGE CARE INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HERITAGE CARE INC
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:
ST THOMAS MORE NURSING & REHAB CENTER
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:
1225035058
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4922 LASALLE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HYATTSVILLE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20782-3302
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-864-2333
Provider Business Mailing Address Fax Number:
301-864-1377

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5711 SARVIS AVE STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RIVERDALE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20737-1363
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-237-6677
Provider Business Practice Location Address Fax Number:
301-576-3987
Provider Enumeration Date:
07/07/2005

Additional Information

Authorized Official

Authorized Official Last Name:
CAICEDO
Authorized Official First Name:
JUAN
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
301-234-6677

Provider Taxonomy Codes

  • Taxonomy code: 261QP2000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 314000000X , with the licence number: 14703200400 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: PM9 . This is a "BLUECROSS BLUESHIELDS" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 800680600 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




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