1922030444 NPI number — HERITAGE HEALTH CENTER INC

Table of content: (NPI 1922030444)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922030444 NPI number — HERITAGE HEALTH CENTER INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HERITAGE HEALTH CENTER 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:
BETTY A BENNETT
Provider Other Organization Name Type Code:
4
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:
1922030444
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:
20696 BOND RD NE
Provider Second Line Business Mailing Address:
SUITE 110
Provider Business Mailing Address City Name:
POULSBO
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98370
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-697-5500
Provider Business Mailing Address Fax Number:
360-697-5522

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
20696 BOND RD NE
Provider Second Line Business Practice Location Address:
SUITE 110
Provider Business Practice Location Address City Name:
POULSBO
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98370
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-697-5500
Provider Business Practice Location Address Fax Number:
360-697-5522
Provider Enumeration Date:
07/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BENNETT
Authorized Official First Name:
BETTY
Authorized Official Middle Name:
ANN
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
360-697-5500

Provider Taxonomy Codes

  • Taxonomy code: 208D00000X , with the licence number:  AP30002493 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 9641366 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com