MEDICARE: HERITAGE VILLAGE 3 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	310400000X	Assisted Living Facility	AL9838C	AZ

General Provider Information

NPI Number	:	1740637651
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HERITAGE VILLAGE 3 LLC

Provider Business Mailing Address
First Line	:	8035 E BROWN RD
Second Line	:	BLDG#3
City	:	MESA
State	:	AZ
Zip	:	85207-3901
Country	:	US
Telephone Number	:	480-388-1499
Fax Number	:

Provider Business Practice Location Address
First Line	:	8035 E BROWN RD
Second Line	:	BLDG#3
City	:	MESA
State	:	AZ
Zip	:	85207-3901
Country	:	US
Telephone Number	:	480-388-1499
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR OF FINANCE
Name	:	JENNIFER HENLEY
Credential	:
Telephone Number	:	480-686-8540

Provider Enumeration Date	:	05/20/2016
Last Update Date	:	05/20/2016

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Directions to “HERITAGE VILLAGE 3 LLC ” Practice Location

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