Provider Demographics
NPI:1982460531
Name:HERITAGE FAMILY MEDICINE, LLC
Entity type:Organization
Organization Name:HERITAGE FAMILY MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BETH
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:LOCKWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:574-248-0630
Mailing Address - Street 1:PO BOX 106
Mailing Address - Street 2:
Mailing Address - City:WAKARUSA
Mailing Address - State:IN
Mailing Address - Zip Code:46573-0106
Mailing Address - Country:US
Mailing Address - Phone:574-900-1191
Mailing Address - Fax:574-900-1193
Practice Address - Street 1:111 N ELKHART ST
Practice Address - Street 2:
Practice Address - City:WAKARUSA
Practice Address - State:IN
Practice Address - Zip Code:46573-2006
Practice Address - Country:US
Practice Address - Phone:574-900-1991
Practice Address - Fax:574-900-1193
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-22
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care