Healthcare Provider Details

I. General information

NPI: 1649863358
Provider Name (Legal Business Name): HEAVENLY LIFE HOMECARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2021
Last Update Date: 02/16/2024
Certification Date: 02/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

591 WILLIE KATE LANE
LAWRENCEVILLE GA
30045
US

IV. Provider business mailing address

591 WILLIE KATE LANE
LAWRENCEVILLE GA
30045
US

V. Phone/Fax

Practice location:
  • Phone: 678-789-3320
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: ANITA OCRAN
Title or Position: ADMINISTRATOR
Credential:
Phone: 678-789-3320