Provider Demographics
NPI:1003801010
Name:HERITAGE HOME HEALTH, LLC
Entity Type:Organization
Organization Name:HERITAGE HOME HEALTH, LLC
Other - Org Name:INTEGRITY HOME HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:DONA
Authorized Official - Middle Name:DENISE
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:870-773-4900
Mailing Address - Street 1:3809 E 9TH ST
Mailing Address - Street 2:SUITE 12
Mailing Address - City:TEXARKANA
Mailing Address - State:AR
Mailing Address - Zip Code:71854-5818
Mailing Address - Country:US
Mailing Address - Phone:870-773-4900
Mailing Address - Fax:870-772-9270
Practice Address - Street 1:3809 E 9TH ST
Practice Address - Street 2:SUITE 12
Practice Address - City:TEXARKANA
Practice Address - State:AR
Practice Address - Zip Code:71854-5818
Practice Address - Country:US
Practice Address - Phone:870-773-4900
Practice Address - Fax:870-772-9270
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-15
Last Update Date:2012-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR4167251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR149721514Medicaid
AR047168Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
AR149721514Medicaid