Provider Demographics
NPI:1386995058
Name:HERITAGE HEALTHCARE GROUP LLC
Entity type:Organization
Organization Name:HERITAGE HEALTHCARE GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:DACY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-208-7620
Mailing Address - Street 1:316 N MILWAUKEE ST
Mailing Address - Street 2:SUITE 208
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53202-5885
Mailing Address - Country:US
Mailing Address - Phone:888-348-6773
Mailing Address - Fax:888-389-9031
Practice Address - Street 1:4356 N KENMORE AVE
Practice Address - Street 2:APT 101
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613-1330
Practice Address - Country:US
Practice Address - Phone:312-550-3612
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL6261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service