Healthcare Provider Details

I. General information

NPI: 1003538471
Provider Name (Legal Business Name): HEARTWOOD AVENUE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2022
Last Update Date: 09/13/2022
Certification Date: 09/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1044 HEARTWOOD AVE
VALLEJO CA
94591-5637
US

IV. Provider business mailing address

4747 VIEWRIDGE AVE STE 105
SAN DIEGO CA
92123-1688
US

V. Phone/Fax

Practice location:
  • Phone: 707-643-2267
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: RICHARD MARTIN
Title or Position: MANAGER
Credential:
Phone: 707-643-2267