Healthcare Provider Details

I. General information

NPI: 1013469881
Provider Name (Legal Business Name): HERITAGE GROUP HOMES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2016
Last Update Date: 06/21/2023
Certification Date: 06/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 COUNTRY WOOD DR
PHILLIPS RANCH CA
91766-4818
US

IV. Provider business mailing address

PO BOX 8400
LA VERNE CA
91750-8400
US

V. Phone/Fax

Practice location:
  • Phone: 909-623-3400
  • Fax: 909-599-8223
Mailing address:
  • Phone: 909-599-8222
  • Fax: 909-599-8223

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number197804150
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name: MARIA SERRATOS
Title or Position: PROGRAM ADMINISTRATOR
Credential:
Phone: 909-599-8222