Provider Demographics
NPI:1336694223
Name:HERITAGE ASSISTED LIVING HOME LLC
Entity Type:Organization
Organization Name:HERITAGE ASSISTED LIVING HOME LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MOLLY
Authorized Official - Middle Name:
Authorized Official - Last Name:BATES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-868-1887
Mailing Address - Street 1:PO BOX 231253
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99523-1253
Mailing Address - Country:US
Mailing Address - Phone:907-868-1887
Mailing Address - Fax:907-868-1887
Practice Address - Street 1:6754 OBRIEN ST
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99507-2184
Practice Address - Country:US
Practice Address - Phone:907-868-1887
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-20
Last Update Date:2016-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK100927320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities