Healthcare Provider Details

I. General information

NPI: 1104236165
Provider Name (Legal Business Name): HERITAGE ENTERPRISES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/30/2014
Last Update Date: 04/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 E WALNUT ST
BLOOMINGTON IL
61701-3244
US

IV. Provider business mailing address

115 W JEFFERSON ST SUITE 401
BLOOMINGTON IL
61701-3946
US

V. Phone/Fax

Practice location:
  • Phone: 309-829-1268
  • Fax: 309-829-3475
Mailing address:
  • Phone: 309-823-7139
  • Fax: 309-829-5477

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DAVID M UNDERWOOD
Title or Position: SR VP & CFO
Credential:
Phone: 309-823-7135