Healthcare Provider Details

I. General information

NPI: 1487824843
Provider Name (Legal Business Name): HERITAGE HOUSE HUMAN SERVICES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2008
Last Update Date: 09/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3557 N SHARON AMITY RD SUITE # 100-103
CHARLOTTE NC
28205-8849
US

IV. Provider business mailing address

3557 N SHARON AMITY RD STE 100-103
CHARLOTTE NC
28205-8849
US

V. Phone/Fax

Practice location:
  • Phone: 917-501-8029
  • Fax:
Mailing address:
  • Phone: 917-501-8029
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251X00000X
TaxonomySupports Brokerage Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. WILLIAM E. ELLIS I
Title or Position: EXECUTIVE DIRECTOR
Credential: BS COMM HEALTH
Phone: 917-501-8029