Provider Demographics
NPI:1851001143
Name:HERON CARE LLC
Entity type:Organization
Organization Name:HERON CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GORDON
Authorized Official - Middle Name:KABUYE
Authorized Official - Last Name:SSEGIMU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-978-2831
Mailing Address - Street 1:3246 E CARLA VISTA DR
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85295-3424
Mailing Address - Country:US
Mailing Address - Phone:478-978-2831
Mailing Address - Fax:
Practice Address - Street 1:3246 E CARLA VISTA DR
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85295-3424
Practice Address - Country:US
Practice Address - Phone:478-978-2831
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-29
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness