Provider Demographics
NPI:1376800672
Name:HERITAGE PLACE ASSISTED LIVING
Entity Type:Organization
Organization Name:HERITAGE PLACE ASSISTED LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:KAYE
Authorized Official - Middle Name:
Authorized Official - Last Name:KIZERIAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-298-3241
Mailing Address - Street 1:1150 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-6351
Mailing Address - Country:US
Mailing Address - Phone:801-298-3241
Mailing Address - Fax:
Practice Address - Street 1:1150 S MAIN ST
Practice Address - Street 2:
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-6351
Practice Address - Country:US
Practice Address - Phone:801-298-3241
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RETIREMENT LIVING GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-04-12
Last Update Date:2012-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2012-ALII-8674310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility