Provider Demographics
NPI:1528363215
Name:HERITAGE HEALTHCARE OF NORTHERN NEW MEXICO, INC
Entity Type:Organization
Organization Name:HERITAGE HEALTHCARE OF NORTHERN NEW MEXICO, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:LEONARD
Authorized Official - Middle Name:J
Authorized Official - Last Name:TRAINOR
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:505-796-3200
Mailing Address - Street 1:3721 RUTLEDGE RD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-5566
Mailing Address - Country:US
Mailing Address - Phone:505-796-3200
Mailing Address - Fax:505-796-3234
Practice Address - Street 1:1012 MILLS AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NM
Practice Address - Zip Code:87701-4049
Practice Address - Country:US
Practice Address - Phone:505-454-9403
Practice Address - Fax:505-454-9445
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HERITAGE HOME HEALTHCARE SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-01-11
Last Update Date:2011-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3358251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM3358Medicaid