Provider Demographics
NPI:1659495703
Name:HERITAGE INN RETIREMENT CENTER LLC
Entity Type:Organization
Organization Name:HERITAGE INN RETIREMENT CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:GWEN
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-723-8099
Mailing Address - Street 1:14901 RIVER ST
Mailing Address - Street 2:
Mailing Address - City:BLAKELY
Mailing Address - State:GA
Mailing Address - Zip Code:39823-2420
Mailing Address - Country:US
Mailing Address - Phone:229-723-8099
Mailing Address - Fax:229-723-6438
Practice Address - Street 1:14901 RIVER ST
Practice Address - Street 2:
Practice Address - City:BLAKELY
Practice Address - State:GA
Practice Address - Zip Code:39823-2420
Practice Address - Country:US
Practice Address - Phone:229-723-8099
Practice Address - Fax:229-723-6438
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-16
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA310400000X310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility