MEDICARE: HERITAGE HOMECARE OF GASTONIA

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	:	1932607108
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HERITAGE HOMECARE OF GASTONIA

Provider Business Mailing Address
First Line	:	1913 J N PEASE PL STE 103
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28262-4537
Country	:	US
Telephone Number	:	704-763-7168
Fax Number	:

Provider Business Practice Location Address
First Line	:	1913 J N PEASE PL STE 103
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28262-4537
Country	:	US
Telephone Number	:	704-763-7168
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. RICO AKIVA WAGNER
Credential	:
Telephone Number	:	704-763-2168

Provider Enumeration Date	:	01/23/2018
Last Update Date	:	10/04/2023

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