Healthcare Provider Details

I. General information

NPI: 1669584298
Provider Name (Legal Business Name): HERITAGE CREEK FAMILY CARE ESTATE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 06/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1662 SMALL TOWN RD
PINK HILL NC
28572-9625
US

IV. Provider business mailing address

1662 SMALL TOWN RD
PINK HILL NC
28572-9625
US

V. Phone/Fax

Practice location:
  • Phone: 252-568-2655
  • Fax: 252-568-2658
Mailing address:
  • Phone: 252-568-2655
  • Fax: 252-568-2658

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License NumberFCL-052-005
License Number StateNC

VIII. Authorized Official

Name: MR. JOSEPH M NEWSOME
Title or Position: DIRECTOR OF MEDICAID BILLING
Credential:
Phone: 252-525-1082