=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104236165
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HERITAGE ENTERPRISES, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/30/2014
-----------------------------------------------------
Last Update Date | 04/30/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 700 E WALNUT ST
-----------------------------------------------------
City | BLOOMINGTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61701-3244
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-829-1268
-----------------------------------------------------
Fax | 309-829-3475
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 115 W JEFFERSON ST SUITE 401
-----------------------------------------------------
City | BLOOMINGTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61701-3946
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-823-7139
-----------------------------------------------------
Fax | 309-829-5477
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SR VP & CFO
-----------------------------------------------------
Name | DAVID M UNDERWOOD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 309-823-7135
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------