1417276460 NPI number — HERITAGE HOME CARE AGENCY INC.

Table of content: (NPI 1417276460)

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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