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General NPI Number Information
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NPI Number | 1942639521
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Entity Type | Organization
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Legal Business Name | HERITAGE AFC HOME
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Dates
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Enumeration Date | 11/05/2013
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Last Update Date | 11/05/2013
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Provider Practice Location Address
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Address Line | 8933 GEORGE AVE
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City | BERRIEN SPRINGS
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State | MI
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Zip | 49103-1576
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Country | US
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Telephone | 269-473-6006
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Fax |
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Provider Business Mailing Address
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Address Line | 8933 GEORGE AVE
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City | BERRIEN SPRINGS
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State | MI
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Zip | 49103-1576
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Country | US
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Telephone | 269-473-6006
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Fax |
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Authorized Official
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Title or Position | LICENSEE/OWNER
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Name | MRS. IRENE F HALDER
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Credential |
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Telephone | 269-473-6006
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 311Z00000X
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Taxonomy Name | Custodial Care Facility
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License Number | AF110320288
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License Number State | MI
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