MEDICARE: HERITAGE PRIDE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	253Z00000X	In Home Supportive Care Agency

General Provider Information

NPI Number	:	1003427238
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HERITAGE PRIDE LLC

Provider Business Mailing Address
First Line	:	4730 FAIRMOUNT ST APT 4302
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75219-1144
Country	:	US
Telephone Number	:	682-320-7070
Fax Number	:

Provider Business Practice Location Address
First Line	:	4730 FAIRMOUNT ST APT 4302
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75219-1144
Country	:	US
Telephone Number	:	682-320-7070
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT/ CEO
Name	:	IKPONMWOSA ERIBO
Credential	:
Telephone Number	:	682-320-7070

Provider Enumeration Date	:	08/12/2020
Last Update Date	:	08/12/2020

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Directions to “HERITAGE PRIDE LLC ” Practice Location

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