Provider Demographics
NPI:1497745723
Name:HERITAGE CONVALESCENT CENTER, LTD
Entity Type:Organization
Organization Name:HERITAGE CONVALESCENT CENTER, LTD
Other - Org Name:HERITAGE CONVALESCENT CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RUEGENA
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIDSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:806-352-5295
Mailing Address - Street 1:1009 CLYDE ST
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79106-4225
Mailing Address - Country:US
Mailing Address - Phone:806-352-5295
Mailing Address - Fax:806-352-6635
Practice Address - Street 1:1009 CLYDE ST
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79106-4225
Practice Address - Country:US
Practice Address - Phone:806-352-5295
Practice Address - Fax:806-352-6635
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX455480Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER