MEDICARE: HERITAGE NURSING, 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	314000000X	Skilled Nursing Facility	030266	MO

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	:	1700883584
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HERITAGE NURSING, LLC

Provider Business Mailing Address
First Line	:	1802 SAINT FRANCIS ST
Second Line	:	P.O. BOX 827
City	:	KENNETT
State	:	MO
Zip	:	63857-1568
Country	:	US
Telephone Number	:	573-888-1044
Fax Number	:	573-888-6036

Provider Business Practice Location Address
First Line	:	1802 SAINT FRANCIS ST
Second Line	:
City	:	KENNETT
State	:	MO
Zip	:	63857-1568
Country	:	US
Telephone Number	:	573-888-1044
Fax Number	:	573-888-6036

Authorized Official
Title or Position	:	TREASURER
Name	:	MR. JAMES REIKER
Credential	:
Telephone Number	:	573-417-1113

Provider Enumeration Date	:	07/07/2005
Last Update Date	:	03/11/2013

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