Provider Demographics
NPI:1154441210
Name:HERITAGE HEALTH NORTHEAST INC
Entity type:Organization
Organization Name:HERITAGE HEALTH NORTHEAST INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:T
Authorized Official - Last Name:NICKELL
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:423-510-9504
Mailing Address - Street 1:6727 HERITAGE BUSINESS CT
Mailing Address - Street 2:SUITE 712
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-7015
Mailing Address - Country:US
Mailing Address - Phone:423-510-9504
Mailing Address - Fax:423-510-9548
Practice Address - Street 1:735 E 10TH ST
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37403-2917
Practice Address - Country:US
Practice Address - Phone:423-510-9504
Practice Address - Fax:423-510-9548
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNP0000001470373H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes373H00000XNursing Service Related ProvidersDay Training/Habilitation SpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3733189Medicaid
TN3733189Medicare ID - Type Unspecified