Provider Demographics
NPI:1740769470
Name:HERITAGE BEHAVIORAL CENTER, LLC
Entity Type:Organization
Organization Name:HERITAGE BEHAVIORAL CENTER, LLC
Other - Org Name:HERITAGE LIVING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ACCOUNTS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SATWANT
Authorized Official - Middle Name:
Authorized Official - Last Name:BHOWRA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-550-4065
Mailing Address - Street 1:PO BOX 47090
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85068-7090
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:17442 N 28TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-1903
Practice Address - Country:US
Practice Address - Phone:602-595-8338
Practice Address - Fax:602-354-7174
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-13
Last Update Date:2020-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAL10796H310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAL10796HOtherSTATE LICENSE NUMBER