Provider Demographics
NPI:1750093050
Name:SHALOM HERITAGE, LLC
Entity type:Organization
Organization Name:SHALOM HERITAGE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:ADEBAYO
Authorized Official - Last Name:OGUNTOLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-845-9165
Mailing Address - Street 1:6748 S DENNIS DR
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85283-5426
Mailing Address - Country:US
Mailing Address - Phone:480-845-9165
Mailing Address - Fax:
Practice Address - Street 1:6748 S DENNIS DR
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85283-5426
Practice Address - Country:US
Practice Address - Phone:480-845-9165
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-19
Last Update Date:2022-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ156294Medicaid