Provider Demographics
NPI:1891832549
Name:HERITAGE RESIDENCE OF COMMUNITY CARE, INC.
Entity Type:Organization
Organization Name:HERITAGE RESIDENCE OF COMMUNITY CARE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:WRIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:563-659-4100
Mailing Address - Street 1:108 INDUSTRIAL ST
Mailing Address - Street 2:
Mailing Address - City:DE WITT
Mailing Address - State:IA
Mailing Address - Zip Code:52742-2063
Mailing Address - Country:US
Mailing Address - Phone:563-659-4100
Mailing Address - Fax:563-659-1120
Practice Address - Street 1:2275 S LINN AVE
Practice Address - Street 2:
Practice Address - City:NEW HAMPTON
Practice Address - State:IA
Practice Address - Zip Code:50659-9412
Practice Address - Country:US
Practice Address - Phone:641-394-2391
Practice Address - Fax:641-394-2704
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA190405320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0896787Medicaid