Provider Demographics
NPI:1528371663
Name:HERITAGE HEALTHCARE
Entity Type:Organization
Organization Name:HERITAGE HEALTHCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH PATHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:SHONDRE
Authorized Official - Middle Name:
Authorized Official - Last Name:CLEMONS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-322-5793
Mailing Address - Street 1:1539 ANNA RUBY LN NW
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30152-8205
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3829 FLOYD RD
Practice Address - Street 2:
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106-8534
Practice Address - Country:US
Practice Address - Phone:770-573-2592
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-19
Last Update Date:2010-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP006951320700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA235Z00000XMedicare Oscar/Certification