Healthcare Provider Details

I. General information

NPI: 1164065736
Provider Name (Legal Business Name): HERITAGE EMS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2019
Last Update Date: 10/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1397 WEIMER RD
TAOS NM
87571-6253
US

IV. Provider business mailing address

5386 SANTA TERESITA DR
SANTA TERESA NM
88008-9204
US

V. Phone/Fax

Practice location:
  • Phone: 575-305-5571
  • Fax:
Mailing address:
  • Phone: 575-305-5571
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code341600000X
TaxonomyAmbulance
License Number
License Number State

VIII. Authorized Official

Name: RONALD LEE KING
Title or Position: PRESIDENT
Credential:
Phone: 575-305-5571