Healthcare Provider Details

I. General information

NPI: 1104155753
Provider Name (Legal Business Name): HERITAGE HEALTHCARE OF NORTHERN NEW MEXICO, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/10/2009
Last Update Date: 01/22/2026
Certification Date: 01/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1012 MILLS AVE
LAS VEGAS NM
87701-4049
US

IV. Provider business mailing address

1012 MILLS AVE
LAS VEGAS NM
87701-4049
US

V. Phone/Fax

Practice location:
  • Phone: 575-522-2323
  • Fax: 575-522-2322
Mailing address:
  • Phone: 575-522-2323
  • Fax: 575-522-2322

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number002570
License Number StateNM

VIII. Authorized Official

Name: SUSAN MARBERRY
Title or Position: CCO
Credential:
Phone: 903-390-4040