Provider Demographics
NPI:1780682468
Name:HERITAGE HEALTH CARE, LLC
Entity Type:Organization
Organization Name:HERITAGE HEALTH CARE, LLC
Other - Org Name:HERITAGE HEALTH CARE CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:EDWARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-471-1113
Mailing Address - Street 1:1630 W 2ND ST
Mailing Address - Street 2:
Mailing Address - City:CHANUTE
Mailing Address - State:KS
Mailing Address - Zip Code:66720-1930
Mailing Address - Country:US
Mailing Address - Phone:620-431-4151
Mailing Address - Fax:620-431-6928
Practice Address - Street 1:1630 W 2ND ST
Practice Address - Street 2:
Practice Address - City:CHANUTE
Practice Address - State:KS
Practice Address - Zip Code:66720-1930
Practice Address - Country:US
Practice Address - Phone:620-431-4151
Practice Address - Fax:620-431-6928
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-07
Last Update Date:2011-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSN067005314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS0100107930Medicaid
KS175249Medicare Oscar/Certification