Provider Demographics
NPI:1063778983
Name:HERITAGE MEDICAL HOUSE CALL
Entity type:Organization
Organization Name:HERITAGE MEDICAL HOUSE CALL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:ALEXANDER
Authorized Official - Last Name:LANE
Authorized Official - Suffix:SR
Authorized Official - Credentials:PA
Authorized Official - Phone:888-461-9765
Mailing Address - Street 1:925 MAIN ST
Mailing Address - Street 2:SUITE 300-13
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30083-3098
Mailing Address - Country:US
Mailing Address - Phone:888-461-9765
Mailing Address - Fax:678-381-1684
Practice Address - Street 1:925 MAIN STREET
Practice Address - Street 2:SUITE 300-13
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30083-3098
Practice Address - Country:US
Practice Address - Phone:888-461-9765
Practice Address - Fax:678-381-1684
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-04
Last Update Date:2012-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA12018049251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003124376AMedicaid