Provider Demographics
NPI:1104155753
Name:HERITAGE HEALTHCARE OF NORTHERN NEW MEXICO, INC.
Entity type:Organization
Organization Name:HERITAGE HEALTHCARE OF NORTHERN NEW MEXICO, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:MS
Authorized Official - First Name:MONIQUE
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:INSALACO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-796-3200
Mailing Address - Street 1:1012 MILLS AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NM
Mailing Address - Zip Code:87701-4049
Mailing Address - Country:US
Mailing Address - Phone:505-454-9403
Mailing Address - Fax:505-425-7682
Practice Address - Street 1:8212 LOUISIANA BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87113-2105
Practice Address - Country:US
Practice Address - Phone:505-796-3200
Practice Address - Fax:505-796-3234
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-10
Last Update Date:2009-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM002570251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health