Provider Demographics
NPI:1467405498
Name:HERITAGE HOME HEALTHCARE OF ARIZONA, INC
Entity Type:Organization
Organization Name:HERITAGE HOME HEALTHCARE OF ARIZONA, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-362-3320
Mailing Address - Street 1:7310 N. 16TH ST.
Mailing Address - Street 2:SUITE 228
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85020
Mailing Address - Country:US
Mailing Address - Phone:602-745-2900
Mailing Address - Fax:602-745-2909
Practice Address - Street 1:7310 N. 16TH ST
Practice Address - Street 2:SUITE 228
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85020
Practice Address - Country:US
Practice Address - Phone:602-745-2900
Practice Address - Fax:602-745-2909
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2017-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZHHA4166251E00000X
251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ135248Medicaid
AZ132889Medicaid
AZ037219Medicare ID - Type UnspecifiedPHX LOCATION