Healthcare Provider Details

I. General information

NPI: 1649442294
Provider Name (Legal Business Name): HERITAGE CHARITABLE ORGANIZATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/24/2008
Last Update Date: 06/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12435 WORNALL RD
KANSAS CITY MO
64145-1119
US

IV. Provider business mailing address

12435 WORNALL RD
KANSAS CITY MO
64145-1119
US

V. Phone/Fax

Practice location:
  • Phone: 816-405-1274
  • Fax: 816-943-1235
Mailing address:
  • Phone: 816-405-1274
  • Fax: 816-943-1235

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code320700000X
TaxonomyPhysical Disabilities Residential Treatment Facility
License Number067295
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MRS. DEBORAH C WASHAM
Title or Position: ADMINISTRATOR
Credential: RN
Phone: 816-405-1274