MEDICARE: HERITAGE BUILDING LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	CH00034866	WA
2	208100000X	Physical Medicine & Rehabilitation Physician	AC00000244	WA
3	225700000X	Massage Therapist	MA60043686	WA
4	208100000X	Physical Medicine & Rehabilitation Physician

General Provider Information

NPI Number	:	1023449006
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HERITAGE BUILDING LLC

Provider Business Mailing Address
First Line	:	4001 HARRISON AVE NW
Second Line	:	STE 102
City	:	OLYMPIA
State	:	WA
Zip	:	98502-5084
Country	:	US
Telephone Number	:	360-740-0888
Fax Number	:	360-350-1445

Provider Business Practice Location Address
First Line	:	4001 HARRISON AVE NW
Second Line	:	STE 102
City	:	OLYMPIA
State	:	WA
Zip	:	98502-5084
Country	:	US
Telephone Number	:	360-956-3627
Fax Number	:	360-350-1445

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. RICHARD LOUIS FAIOLA
Credential	:	M.D.
Telephone Number	:	360-704-2362

Provider Enumeration Date	:	12/02/2013
Last Update Date	:	04/01/2014

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Directions to “HERITAGE BUILDING LLC ” Practice Location

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