Provider Demographics
NPI:1316643315
Name:H.E.R.O. INSTITUTE LLC
Entity type:Organization
Organization Name:H.E.R.O. INSTITUTE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:MRS
Authorized Official - First Name:VICTORIA
Authorized Official - Middle Name:
Authorized Official - Last Name:RANDLE
Authorized Official - Suffix:
Authorized Official - Credentials:NP-C
Authorized Official - Phone:770-726-3577
Mailing Address - Street 1:5284 FLOYD RD SW UNIT 842
Mailing Address - Street 2:
Mailing Address - City:MABLETON
Mailing Address - State:GA
Mailing Address - Zip Code:30126-6106
Mailing Address - Country:US
Mailing Address - Phone:770-726-3577
Mailing Address - Fax:770-522-6228
Practice Address - Street 1:6130 HOTEL ST
Practice Address - Street 2:
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106-4623
Practice Address - Country:US
Practice Address - Phone:770-726-3577
Practice Address - Fax:770-522-6228
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-01
Last Update Date:2024-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003167991KMedicaid
GARN199251OtherNP LICENSE NUMBER