MEDICARE: HERITAGE MEDICAL HOUSE CALL

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	251E00000X	Home Health Agency	12018049	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1063778983
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HERITAGE MEDICAL HOUSE CALL

Provider Business Mailing Address
First Line	:	925 MAIN ST
Second Line	:	SUITE 300-13
City	:	STONE MOUNTAIN
State	:	GA
Zip	:	30083-3098
Country	:	US
Telephone Number	:	888-461-9765
Fax Number	:	678-381-1684

Provider Business Practice Location Address
First Line	:	925 MAIN STREET
Second Line	:	SUITE 300-13
City	:	STONE MOUNTAIN
State	:	GA
Zip	:	30083-3098
Country	:	US
Telephone Number	:	888-461-9765
Fax Number	:	678-381-1684

Authorized Official
Title or Position	:	OWNER/MEMBER
Name	:	MR. KEVIN ALEXANDER LANE SR.
Credential	:	PA
Telephone Number	:	888-461-9765

Provider Enumeration Date	:	04/04/2012
Last Update Date	:	10/31/2012

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Directions to “HERITAGE MEDICAL HOUSE CALL ” Practice Location

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