Provider Demographics
NPI:1669462321
Name:HERITAGE HOSPICE, INC.
Entity Type:Organization
Organization Name:HERITAGE HOSPICE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:AMBROSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-429-1845
Mailing Address - Street 1:1202 W. BUENA VISTA RD
Mailing Address - Street 2:SUITE 107
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47710
Mailing Address - Country:US
Mailing Address - Phone:812-475-9712
Mailing Address - Fax:812-475-9716
Practice Address - Street 1:1202 W. BUENA VISTA RD
Practice Address - Street 2:SUITE 107
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47710
Practice Address - Country:US
Practice Address - Phone:812-475-9712
Practice Address - Fax:812-475-9716
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-25
Last Update Date:2017-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN07-0004208-01251G00000X
IN004208-1314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200513260Medicaid
IN200513260AMedicaid
477101Medicare PIN
IN200513260Medicaid