Healthcare Provider Details

I. General information

NPI: 1962828103
Provider Name (Legal Business Name): HEAVENLY HEALTH SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2014
Last Update Date: 08/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

388 SW 163RD AVE
PEMBROKE PINES FL
33027-1084
US

IV. Provider business mailing address

388 SW 163RD AVE
PEMBROKE PINES FL
33027-1084
US

V. Phone/Fax

Practice location:
  • Phone: 954-673-4065
  • Fax:
Mailing address:
  • Phone: 954-673-4065
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number3082172
License Number StateFL

VIII. Authorized Official

Name: MRS. EVA MIREILLE JACQUES
Title or Position: PROPRIATOR
Credential: ARNP
Phone: 954-673-4065