Healthcare Provider Details

I. General information

NPI: 1023234747
Provider Name (Legal Business Name): HERITAGE CLINIC AND THE COMMUNITY ASSISTANCE PROGRAM FOR SENIORS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2007
Last Update Date: 02/17/2022
Certification Date: 02/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43807 10TH ST W STE D
LANCASTER CA
93534-4805
US

IV. Provider business mailing address

447 N EL MOLINO AVE
PASADENA CA
91101-1403
US

V. Phone/Fax

Practice location:
  • Phone: 661-575-9365
  • Fax: 661-575-9502
Mailing address:
  • Phone: 626-577-8480
  • Fax: 626-577-8978

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY19717
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251X00000X
TaxonomySupports Brokerage Agency
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: MR. VATCHE KELARTINIAN
Title or Position: CFO
Credential: MBA
Phone: 626-577-8480