MEDICARE: HERITAGE HEALTHCARE OF NORTHERN NEW MEXICO, INC

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	002570	NM

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	7068	OTHER	NM	LICENSE

General Provider Information

NPI Number	:	1104155753
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HERITAGE HEALTHCARE OF NORTHERN NEW MEXICO, INC

Provider Business Mailing Address
First Line	:	1012 MILLS AVE
Second Line	:
City	:	LAS VEGAS
State	:	NM
Zip	:	87701-4049
Country	:	US
Telephone Number	:	575-522-2323
Fax Number	:	575-522-2322

Provider Business Practice Location Address
First Line	:	1012 MILLS AVE
Second Line	:
City	:	LAS VEGAS
State	:	NM
Zip	:	87701-4049
Country	:	US
Telephone Number	:	575-522-2323
Fax Number	:	575-522-2322

Authorized Official
Title or Position	:	CCO
Name	:	SUSAN MARBERRY
Credential	:
Telephone Number	:	903-390-4040

Provider Enumeration Date	:	12/10/2009
Last Update Date	:	01/22/2026

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