Provider Demographics
NPI:1487883476
Name:HERITAGE HABILITATION INCORPORATED
Entity type:Organization
Organization Name:HERITAGE HABILITATION INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:HERYN
Authorized Official - Middle Name:ORI- ADE'
Authorized Official - Last Name:DONALD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-899-1193
Mailing Address - Street 1:PO BOX 1405
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76095-1405
Mailing Address - Country:US
Mailing Address - Phone:817-899-1193
Mailing Address - Fax:
Practice Address - Street 1:746 E PIPELINE RD
Practice Address - Street 2:
Practice Address - City:HURST
Practice Address - State:TX
Practice Address - Zip Code:76053-6011
Practice Address - Country:US
Practice Address - Phone:817-899-1193
Practice Address - Fax:817-280-0200
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-10
Last Update Date:2009-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities