Basic Information
| Provider Information | |||||||||
| NPI: | 1114584208 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HERITAGE TECHNOLOGIES, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 24573 | ||||||||
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| City: | BELFAST | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049154496 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8556600300 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1855 N STAPLEY DR | ||||||||
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| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852033002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4806327942 | ||||||||
| FaxNumber: | 4808338313 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2019 | ||||||||
| LastUpdateDate: | 05/23/2019 | ||||||||
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| AuthorizedOfficialLastName: | DINSDALE | ||||||||
| AuthorizedOfficialFirstName: | MICHELLE | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4808347546 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.