Healthcare Provider Details

I. General information

NPI: 1134467251
Provider Name (Legal Business Name): HEAVENLY ARMS ASSISTED LIVING PERSONAL CARE HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2013
Last Update Date: 01/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11230 HIGHWAY 278 E
COVINGTON GA
30014-1673
US

IV. Provider business mailing address

11230 HIGHWAY 278 E
COVINGTON GA
30014-1673
US

V. Phone/Fax

Practice location:
  • Phone: 678-625-4216
  • Fax: 678-625-7793
Mailing address:
  • Phone: 678-625-4216
  • Fax: 678-625-7793

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License NumberBLP-18639
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License NumberBLP-18639
License Number StateGA

VIII. Authorized Official

Name: VIDA A L THOMPSON
Title or Position: OWNER
Credential:
Phone: 678-625-4216