Healthcare Provider Details

I. General information

NPI: 1750748166
Provider Name (Legal Business Name): HEAVENLY FOODS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/15/2016
Last Update Date: 01/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4040 SW 69TH AVE
MIRAMAR FL
33023-6688
US

IV. Provider business mailing address

4040 SW 69TH AVE
MIRAMAR FL
33023-6688
US

V. Phone/Fax

Practice location:
  • Phone: 786-426-2611
  • Fax: 954-404-7601
Mailing address:
  • Phone: 786-426-2611
  • Fax: 954-404-7601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332U00000X
TaxonomyHome Delivered Meals
License NumberSEA1617838
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code335G00000X
TaxonomyMedical Foods Supplier
License NumberSEA1617838
License Number StateFL

VIII. Authorized Official

Name: PASHUN DOBSON
Title or Position: OWNER
Credential:
Phone: 786-426-2611