Healthcare Provider Details

I. General information

NPI: 1174958474
Provider Name (Legal Business Name): HEAVENLY ANGEL WINGS RETIREMENT HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/05/2013
Last Update Date: 09/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8404 KNIFLEY RD
COLUMBIA KY
42728-7505
US

IV. Provider business mailing address

8404 KNIFLEY RD
COLUMBIA KY
42728-7505
US

V. Phone/Fax

Practice location:
  • Phone: 270-250-4051
  • Fax:
Mailing address:
  • Phone: 270-250-4051
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320700000X
TaxonomyPhysical Disabilities Residential Treatment Facility
License Number
License Number StateKY

VIII. Authorized Official

Name: CHARLES CRAWHORN
Title or Position: CEO
Credential:
Phone: 270-250-4051