Healthcare Provider Details

I. General information

NPI: 1154441210
Provider Name (Legal Business Name): HERITAGE HEALTH NORTHEAST INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/30/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

735 E 10TH ST
CHATTANOOGA TN
37403-2917
US

IV. Provider business mailing address

6727 HERITAGE BUSINESS CT SUITE 712
CHATTANOOGA TN
37421-7015
US

V. Phone/Fax

Practice location:
  • Phone: 423-510-9504
  • Fax: 423-510-9548
Mailing address:
  • Phone: 423-510-9504
  • Fax: 423-510-9548

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License NumberP0000001470
License Number StateTN

VIII. Authorized Official

Name: GERALD T NICKELL
Title or Position: PRESIDENT
Credential: CPA
Phone: 423-510-9504