Healthcare Provider Details

I. General information

NPI: 1023449006
Provider Name (Legal Business Name): HERITAGE BUILDING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2013
Last Update Date: 04/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4001 HARRISON AVE NW STE 102
OLYMPIA WA
98502-5084
US

IV. Provider business mailing address

4001 HARRISON AVE NW STE 102
OLYMPIA WA
98502-5084
US

V. Phone/Fax

Practice location:
  • Phone: 360-956-3627
  • Fax: 360-350-1445
Mailing address:
  • Phone: 360-740-0888
  • Fax: 360-350-1445

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCH00034866
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberAC00000244
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA60043686
License Number StateWA
# 4
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. RICHARD LOUIS FAIOLA
Title or Position: PRESIDENT
Credential: M.D.
Phone: 360-704-2362