Provider Demographics
NPI:1588640833
Name:HERITAGE HEALTHCARE INC
Entity Type:Organization
Organization Name:HERITAGE HEALTHCARE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROLL
Authorized Official - Suffix:
Authorized Official - Credentials:2984
Authorized Official - Phone:918-335-3222
Mailing Address - Street 1:1244 WOODLAND LOOP
Mailing Address - Street 2:
Mailing Address - City:BARTLESVILLE
Mailing Address - State:OK
Mailing Address - Zip Code:74006-5224
Mailing Address - Country:US
Mailing Address - Phone:918-335-3222
Mailing Address - Fax:918-333-5111
Practice Address - Street 1:1244 WOODLAND LOOP
Practice Address - Street 2:
Practice Address - City:BARTLESVILLE
Practice Address - State:OK
Practice Address - Zip Code:74006-5224
Practice Address - Country:US
Practice Address - Phone:918-335-3222
Practice Address - Fax:918-333-5111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKNH74057405314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK375109Medicare ID - Type Unspecified