Basic Information
| Provider Information | |||||||||
| NPI: | 1174511224 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HERITAGE HOUSE OF CLINTON, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 375 S 11TH ST | ||||||||
| Address2: | |||||||||
| City: | CLINTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 478421053 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7658322491 | ||||||||
| FaxNumber: | 7658322685 | ||||||||
| Practice Location | |||||||||
| Address1: | 375 S 11TH ST | ||||||||
| Address2: | |||||||||
| City: | CLINTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 478421053 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7658322491 | ||||||||
| FaxNumber: | 7658322685 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | BROWN | ||||||||
| AuthorizedOfficialFirstName: | PHILLIP | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3173986809 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | IN | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.