Provider Demographics
NPI:1558333039
Name:HERITAGE HEALTH SERVICES, INC
Entity Type:Organization
Organization Name:HERITAGE HEALTH SERVICES, INC
Other - Org Name:NEW LONDON HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:T
Authorized Official - Last Name:MCKETTRICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-650-8922
Mailing Address - Street 1:454C FURYS FERRY RD
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30907-9506
Mailing Address - Country:US
Mailing Address - Phone:706-650-8922
Mailing Address - Fax:706-650-8984
Practice Address - Street 1:2020 MCGEE RD
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-2992
Practice Address - Country:US
Practice Address - Phone:770-978-7250
Practice Address - Fax:770-978-7149
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-07
Last Update Date:2007-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1-067-1298314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA11-5771Medicare ID - Type Unspecified