Provider Demographics
NPI:1841674488
Name:HERITAGE HEALTH SERVICES, LLC.
Entity type:Organization
Organization Name:HERITAGE HEALTH SERVICES, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR/DIRECTOR OF NURSING
Authorized Official - Prefix:
Authorized Official - First Name:RACHEL
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:262-939-5000
Mailing Address - Street 1:6634 DURAND AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:WI
Mailing Address - Zip Code:53406-4963
Mailing Address - Country:US
Mailing Address - Phone:262-554-8800
Mailing Address - Fax:
Practice Address - Street 1:6634 DURAND AVE
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:WI
Practice Address - Zip Code:53406-4963
Practice Address - Country:US
Practice Address - Phone:262-554-8800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-14
Last Update Date:2015-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100037194Medicaid