MEDICARE: HERITAGE LABORATORY 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	291U00000X	Clinical Medical Laboratory

General Provider Information

NPI Number	:	1457996522
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HERITAGE LABORATORY INC

Provider Business Mailing Address
First Line	:	25716 S STONEY ISLAND AVE
Second Line	:
City	:	CRETE
State	:	IL
Zip	:	60417-8020
Country	:	US
Telephone Number	:	224-735-6279
Fax Number	:

Provider Business Practice Location Address
First Line	:	7895 BROADWAY STE V1
Second Line	:
City	:	MERRILLVILLE
State	:	IN
Zip	:	46410-5529
Country	:	US
Telephone Number	:	224-735-6279
Fax Number	:

Authorized Official
Title or Position	:	MANAGING DIRECTOR
Name	:	JESUS RAMIREZ
Credential	:
Telephone Number	:	224-735-6279

Provider Enumeration Date	:	11/13/2019
Last Update Date	:	07/14/2021

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