MEDICARE: HEAVENLY HANDS HOMECARE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	372600000X	Adult Companion
2	3747P1801X	Personal Care Attendant
3	374U00000X	Home Health Aide
4	376J00000X	Homemaker
5	253Z00000X	In Home Supportive Care Agency

General Provider Information

NPI Number	:	1245983444
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HEAVENLY HANDS HOMECARE LLC

Provider Business Mailing Address
First Line	:	5009 BRENTWOOD STAIR RD STE 103
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76112-2859
Country	:	US
Telephone Number	:	817-888-3112
Fax Number	:	817-888-3112

Provider Business Practice Location Address
First Line	:	5009 BRENTWOOD STAIR RD STE 103
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76112-2859
Country	:	US
Telephone Number	:	817-888-3112
Fax Number	:	817-888-3112

Authorized Official
Title or Position	:	PRESIDENT/ADMIN
Name	:	KEISHA JOHNSON
Credential	:
Telephone Number	:	817-891-3217

Provider Enumeration Date	:	01/28/2022
Last Update Date	:	04/19/2023

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