MEDICARE: HERITAGE HEALTHCARE INC

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	314000000X	Skilled Nursing Facility	NH74057405	OK

General Provider Information

NPI Number	:	1588640833
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HERITAGE HEALTHCARE INC

Provider Business Mailing Address
First Line	:	1244 WOODLAND LOOP
Second Line	:
City	:	BARTLESVILLE
State	:	OK
Zip	:	74006-5224
Country	:	US
Telephone Number	:	918-335-3222
Fax Number	:	918-333-5111

Provider Business Practice Location Address
First Line	:	1244 WOODLAND LOOP
Second Line	:
City	:	BARTLESVILLE
State	:	OK
Zip	:	74006-5224
Country	:	US
Telephone Number	:	918-335-3222
Fax Number	:	918-333-5111

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MS. LISA ROLL
Credential	:	2984
Telephone Number	:	918-335-3222

Provider Enumeration Date	:	12/19/2005
Last Update Date	:	08/22/2020

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