Provider Demographics
NPI:1699761908
Name:HERITAGE HOME OF FLORENCE, INC
Entity type:Organization
Organization Name:HERITAGE HOME OF FLORENCE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:SHERWIN
Authorized Official - Middle Name:
Authorized Official - Last Name:WELCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-662-4573
Mailing Address - Street 1:515 WARLEY ST
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29501-5132
Mailing Address - Country:US
Mailing Address - Phone:843-662-4573
Mailing Address - Fax:843-662-8209
Practice Address - Street 1:515 WARLEY ST
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29501-5132
Practice Address - Country:US
Practice Address - Phone:843-662-4573
Practice Address - Fax:843-662-8209
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-22
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCNCF-450314000000X
SC0450NH332BN1400X, 332BP3500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No332BN1400XSuppliersDurable Medical Equipment & Medical SuppliesNursing Facility Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC0450NHMedicaid
SC425154Medicare ID - Type Unspecified
SC0450NHMedicaid