MEDICARE: HEAVENLY VIRTUES, LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
2	103K00000X	Behavior Analyst
3	385HR2060X	Child Intellectual and/or Developmental Disabilities Respite Care
4	261QD1600X	Developmental Disabilities Clinic/Center

General Provider Information

NPI Number	:	1659720902
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HEAVENLY VIRTUES, LLC

Provider Business Mailing Address
First Line	:	6261 WAUCONDA WAY W
Second Line	:
City	:	LAKE WORTH
State	:	FL
Zip	:	33463-5871
Country	:	US
Telephone Number	:	561-577-0893
Fax Number	:

Provider Business Practice Location Address
First Line	:	6261 WAUCONDA WAY W
Second Line	:
City	:	LAKE WORTH
State	:	FL
Zip	:	33463-5871
Country	:	US
Telephone Number	:	561-577-0893
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JANET CARR-PRIESTER
Credential	:
Telephone Number	:	561-577-0893

Provider Enumeration Date	:	06/08/2016
Last Update Date	:	06/17/2016

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Directions to “HEAVENLY VIRTUES, LLC ” Practice Location

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