1417276460 NPI number — HERITAGE HOME CARE AGENCY INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417276460 NPI number — HERITAGE HOME CARE AGENCY INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HERITAGE HOME CARE AGENCY 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:
HERITAGE HOME CARE OF GREENSBORO INC.
Provider Other Organization Name Type Code:
5
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:
1417276460
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/11/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 14896
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREENSBORO
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27415-4896
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-779-4667
Provider Business Mailing Address Fax Number:
866-401-7629

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
914 N ELM ST STE D
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GREENSBORO
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27401-6319
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-779-4667
Provider Business Practice Location Address Fax Number:
866-401-7629
Provider Enumeration Date:
05/28/2010

Additional Information

Authorized Official

Authorized Official Last Name:
WAGNER
Authorized Official First Name:
RICO
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
704-779-4667

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  HC3586 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 253Z00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3418319 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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