Provider Demographics
NPI:1235200031
Name:HERITAGE FAMILY CARE,LLC
Entity Type:Organization
Organization Name:HERITAGE FAMILY CARE,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICKEY
Authorized Official - Middle Name:
Authorized Official - Last Name:PICKLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-878-2637
Mailing Address - Street 1:1 MARYLAND FARMS
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-5006
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1910 HILLBROOK TRAIL
Practice Address - Street 2:SUITE 2
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32311
Practice Address - Country:US
Practice Address - Phone:850-878-2637
Practice Address - Fax:850-878-2053
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL=========OtherTAX ID NUMBER