Provider Demographics
NPI:1881167922
Name:HERITAGE TRANSPORTATION
Entity type:Organization
Organization Name:HERITAGE TRANSPORTATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:ASHLEY
Authorized Official - Last Name:FULLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:470-295-4333
Mailing Address - Street 1:4007 CINNAMON FERN LN
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30189-6910
Mailing Address - Country:US
Mailing Address - Phone:678-234-3989
Mailing Address - Fax:
Practice Address - Street 1:4007 CINNAMON FERN LN
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30189-6910
Practice Address - Country:US
Practice Address - Phone:678-234-3989
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-10
Last Update Date:2019-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA343900000XMedicaid