Provider Demographics
NPI:1245642594
Name:HERITAGE VILLAGE,5
Entity type:Organization
Organization Name:HERITAGE VILLAGE,5
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGEMENT/OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:STAN
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:HOSAC
Authorized Official - Suffix:
Authorized Official - Credentials:MANAGER
Authorized Official - Phone:480-686-8540
Mailing Address - Street 1:8035 E BROWN RD
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85207-3900
Mailing Address - Country:US
Mailing Address - Phone:480-686-8540
Mailing Address - Fax:
Practice Address - Street 1:8035 E BROWN RD
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85207-3900
Practice Address - Country:US
Practice Address - Phone:480-686-8540
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-21
Last Update Date:2014-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAL9267C310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility