1619085289 NPI number — HERITAGE HOME HEALTH CARE OF ARIZONIA

Table of content: (NPI 1619085289)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619085289 NPI number — HERITAGE HOME HEALTH CARE OF ARIZONIA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HERITAGE HOME HEALTH CARE OF ARIZONIA
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:
Provider Other Organization Name Type Code:
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:
1619085289
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8212 LOUISIANA BLVD NE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALBUQUERQUE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87113-2105
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-796-3200
Provider Business Mailing Address Fax Number:
505-796-3234

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2250 US HIGHWAY 60
Provider Second Line Business Practice Location Address:
SUITE J
Provider Business Practice Location Address City Name:
MIAMI
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85539-7715
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-402-0060
Provider Business Practice Location Address Fax Number:
928-402-0080
Provider Enumeration Date:
08/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BOURNE
Authorized Official First Name:
STEVE
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
505-796-3236

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  HHA4002 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 136418 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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