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General NPI Number Information
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NPI Number | 1386995058
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Entity Type | Organization
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Legal Business Name | HERITAGE HEALTHCARE GROUP LLC
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Dates
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Enumeration Date | 09/21/2012
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 4356 N KENMORE AVE APT 101
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City | CHICAGO
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State | IL
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Zip | 60613-1330
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Country | US
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Telephone | 312-550-3612
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Fax |
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Provider Business Mailing Address
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Address Line | 316 N MILWAUKEE ST SUITE 208
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City | MILWAUKEE
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State | WI
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Zip | 53202-5885
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Country | US
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Telephone | 888-348-6773
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Fax | 888-389-9031
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | ANDREW DACY
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Credential |
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Telephone | 847-208-7620
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QH0100X
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Taxonomy Name | Health Service Clinic/Center
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License Number | 6
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License Number State | IL
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