Healthcare Provider Details

I. General information

NPI: 1114342169
Provider Name (Legal Business Name): HEAVENLY SOLES PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2014
Last Update Date: 11/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13954 W WADDELL RD SUITE 307
SURPRISE AZ
85379-8750
US

IV. Provider business mailing address

13954 W WADDELL RD SUITE 307
SURPRISE AZ
85379-8750
US

V. Phone/Fax

Practice location:
  • Phone: 623-584-0760
  • Fax: 623-546-0344
Mailing address:
  • Phone: 623-584-0760
  • Fax: 623-546-0344

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP1100X
TaxonomyPodiatric Clinic/Center
License Number0711
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code3104A0630X
TaxonomyAssisted Living Facility (Behavioral Disturbances)
License Number0711
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code311500000X
TaxonomyAlzheimer Center (Dementia Center)
License Number0711
License Number StateAZ
# 4
Primary TaxonomyN
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number0711
License Number StateAZ
# 5
Primary TaxonomyN
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License Number0711
License Number StateAZ
# 6
Primary TaxonomyY
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number0711
License Number StateAZ

VIII. Authorized Official

Name: DR. MARIE C PAUL
Title or Position: MANAGER
Credential: DPM
Phone: 623-584-0760