Provider Demographics
NPI:1881720001
Name:HERITAGE PROVIDER NETWORK, INC.
Entity type:Organization
Organization Name:HERITAGE PROVIDER NETWORK, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF FFS
Authorized Official - Prefix:MRS
Authorized Official - First Name:CARLA
Authorized Official - Middle Name:
Authorized Official - Last Name:COURTNEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:661-726-3805
Mailing Address - Street 1:PO BOX 7007
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93539-7007
Mailing Address - Country:US
Mailing Address - Phone:661-726-3805
Mailing Address - Fax:661-726-3862
Practice Address - Street 1:8510 BALBOA BLVD
Practice Address - Street 2:SUITE 275
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91325-3583
Practice Address - Country:US
Practice Address - Phone:818-654-3400
Practice Address - Fax:818-654-3460
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-23
Last Update Date:2007-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization