Healthcare Provider Details

I. General information

NPI: 1922620608
Provider Name (Legal Business Name): HERITAGE CORNER NURSING HOME, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2020
Last Update Date: 01/14/2021
Certification Date: 01/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1069 KLOTZ RD
BOWLING GREEN OH
43402-4828
US

IV. Provider business mailing address

1069 KLOTZ RD
BOWLING GREEN OH
43402-4828
US

V. Phone/Fax

Practice location:
  • Phone: 317-806-6775
  • Fax:
Mailing address:
  • Phone: 419-728-7009
  • Fax: 419-353-5219

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: LESLIE DIMICK
Title or Position: BUSINESS OFFICE MANAGER
Credential:
Phone: 419-728-7015