Healthcare Provider Details

I. General information

NPI: 1477406536
Provider Name (Legal Business Name): HERITAGE HAVEN HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/18/2026
Last Update Date: 02/18/2026
Certification Date: 02/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6031 AVON ST
PORTAGE MI
49024-2627
US

IV. Provider business mailing address

6031 AVON ST
PORTAGE MI
49024-2627
US

V. Phone/Fax

Practice location:
  • Phone: 269-532-4520
  • Fax: 206-657-5255
Mailing address:
  • Phone: 269-532-4520
  • Fax: 206-665-5255

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. BOLAJI S INUOLAJI
Title or Position: ADMINISTRATOR
Credential:
Phone: 269-532-4520