MEDICARE: HERITAGE CHARITABLE ORGANIZATION

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	320700000X	Physical Disabilities Residential Treatment Facility	067295	MO
2	320600000X	Intellectual and/or Developmental Disabilities Residential Treatment Facility

General Provider Information

NPI Number	:	1649442294
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HERITAGE CHARITABLE ORGANIZATION

Provider Business Mailing Address
First Line	:	12435 WORNALL RD
Second Line	:
City	:	KANSAS CITY
State	:	MO
Zip	:	64145-1119
Country	:	US
Telephone Number	:	816-405-1274
Fax Number	:	816-943-1235

Provider Business Practice Location Address
First Line	:	12435 WORNALL RD
Second Line	:
City	:	KANSAS CITY
State	:	MO
Zip	:	64145-1119
Country	:	US
Telephone Number	:	816-405-1274
Fax Number	:	816-943-1235

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MRS. DEBORAH C WASHAM
Credential	:	RN
Telephone Number	:	816-405-1274

Provider Enumeration Date	:	03/24/2008
Last Update Date	:	06/16/2008

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Directions to “HERITAGE CHARITABLE ORGANIZATION ” Practice Location

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