Provider Demographics
NPI:1922620608
Name:HERITAGE CORNER NURSING HOME, LLC
Entity Type:Organization
Organization Name:HERITAGE CORNER NURSING HOME, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:DIMICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-728-7015
Mailing Address - Street 1:1069 KLOTZ RD
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:OH
Mailing Address - Zip Code:43402-4828
Mailing Address - Country:US
Mailing Address - Phone:419-728-7009
Mailing Address - Fax:419-353-5219
Practice Address - Street 1:1069 KLOTZ RD
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:OH
Practice Address - Zip Code:43402-4828
Practice Address - Country:US
Practice Address - Phone:317-806-6775
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-15
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility