Provider Demographics
NPI:1376604934
Name:HERRITAGE HOMES LLC
Entity Type:Organization
Organization Name:HERRITAGE HOMES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SAM
Authorized Official - Middle Name:
Authorized Official - Last Name:SEYMOUR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-635-7678
Mailing Address - Street 1:45 N 100 W
Mailing Address - Street 2:
Mailing Address - City:HURRICANE
Mailing Address - State:UT
Mailing Address - Zip Code:84737-1603
Mailing Address - Country:US
Mailing Address - Phone:435-635-7678
Mailing Address - Fax:435-216-1155
Practice Address - Street 1:45 N 100 W
Practice Address - Street 2:
Practice Address - City:HURRICANE
Practice Address - State:UT
Practice Address - Zip Code:84737-1603
Practice Address - Country:US
Practice Address - Phone:435-635-7678
Practice Address - Fax:435-216-1155
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2010-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT=========001Medicaid