Provider Demographics
NPI:1023449006
Name:HERITAGE BUILDING LLC
Entity type:Organization
Organization Name:HERITAGE BUILDING LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
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:STE 102
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502-5084
Mailing Address - Country:US
Mailing Address - Phone:360-740-0888
Mailing Address - Fax:360-350-1445
Practice Address - Street 1:4001 HARRISON AVE NW
Practice Address - Street 2:STE 102
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-5084
Practice Address - Country:US
Practice Address - Phone:360-956-3627
Practice Address - Fax:360-350-1445
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-02
Last Update Date:2014-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00034866111N00000X
WAAC00000244208100000X
WAMA60043686225700000X
208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty