Healthcare Provider Details

I. General information

NPI: 1487883476
Provider Name (Legal Business Name): HERITAGE HABILITATION INCORPORATED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2009
Last Update Date: 07/10/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

746 E PIPELINE RD
HURST TX
76053-6011
US

IV. Provider business mailing address

PO BOX 1405
BEDFORD TX
76095-1405
US

V. Phone/Fax

Practice location:
  • Phone: 817-899-1193
  • Fax: 817-280-0200
Mailing address:
  • Phone: 817-899-1193
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. HERYN ORI- ADE' DONALD
Title or Position: PROGRAM MANAGER
Credential:
Phone: 817-899-1193