1699004853 NPI number — HERITAGE FAMILY MEDICINE LLC

Table of content: (NPI 1699004853)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699004853 NPI number — HERITAGE FAMILY MEDICINE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HERITAGE FAMILY MEDICINE 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:
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:
1699004853
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/15/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4931 E MAYFLOWER LN
Provider Second Line Business Mailing Address:
SUITE 1
Provider Business Mailing Address City Name:
WASILLA
Provider Business Mailing Address State Name:
AK
Provider Business Mailing Address Postal Code:
99654-7759
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
907-376-5337
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4961 E MAYFLOWER LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WASILLA
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99654-7708
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-376-5337
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/17/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SAHLSTROM
Authorized Official First Name:
CHRISTOPHER
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
907-982-5300

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  6506 , registered in the state of AK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: MD0506 , issued by the state of ( AK ) . This identifiers is of the category "MEDICAID".
  • Identifier: MPG0164 , issued by the state of ( AK ) . This identifiers is of the category "MEDICAID".