Healthcare Provider Details

I. General information

NPI: 1366367690
Provider Name (Legal Business Name): NEW HERITAGE COLLECTIVE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/13/2026
Last Update Date: 08/13/2026
Certification Date: 07/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4030 WAKE FOREST RD STE 349
RALEIGH NC
27609-0010
US

IV. Provider business mailing address

PO BOX 23194
MINT HILL NC
28227-0274
US

V. Phone/Fax

Practice location:
  • Phone: 704-970-8200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: JESSE TALL
Title or Position: FOUNDER/MANAGER
Credential:
Phone: 704-975-6118