=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104172634
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HERITAGE HEALTH CARE, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/02/2012
-----------------------------------------------------
Last Update Date | 08/02/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 25271 BARTON RD
-----------------------------------------------------
City | LOMA LINDA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92354-3013
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-796-0219
-----------------------------------------------------
Fax | 909-796-3496
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 3000
-----------------------------------------------------
City | LOMA LINDA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92354-9000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-796-2595
-----------------------------------------------------
Fax | 909-796-8797
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF FINANCIAL OFFICER
-----------------------------------------------------
Name | MR. JAMES B KILIAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 909-796-2595
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | 360900455
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------