Provider Demographics
NPI:1427136977
Name:HERITAGE FAMILY MEDICINE
Entity type:Organization
Organization Name:HERITAGE FAMILY MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:LOUIS
Authorized Official - Last Name:FAIOLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:360-704-2362
Mailing Address - Street 1:4001 HARRISON AVE NW
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502-5084
Mailing Address - Country:US
Mailing Address - Phone:360-704-2362
Mailing Address - Fax:360-350-1445
Practice Address - Street 1:4001 HARRISON AVE NW STE 101
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-5084
Practice Address - Country:US
Practice Address - Phone:360-704-2362
Practice Address - Fax:360-350-1445
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2021-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA6220HEOtherGROUP RIDER
WA0219928OtherLABOR AND INDUSTRIES WA
WA7136914Medicaid
WA7136914Medicaid