Healthcare Provider Details

I. General information

NPI: 1609486216
Provider Name (Legal Business Name): HERITAGE VILLAGE BLDG1 LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2020
Last Update Date: 08/07/2020
Certification Date: 08/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8035 E BROWN RD
MESA AZ
85207-3901
US

IV. Provider business mailing address

8035 E BROWN RD
MESA AZ
85207-3901
US

V. Phone/Fax

Practice location:
  • Phone: 480-686-8540
  • Fax:
Mailing address:
  • Phone: 480-686-8540
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code311500000X
TaxonomyAlzheimer Center (Dementia Center)
License Number
License Number State

VIII. Authorized Official

Name: NATE PORTER
Title or Position: CHIEF MARKETING OFFICER
Credential:
Phone: 801-644-3640