Healthcare Provider Details

I. General information

NPI: 1740489152
Provider Name (Legal Business Name): HEAVENLY HAVEN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2007
Last Update Date: 07/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4824 E BROOKSTOWN DR
BATON ROUGE LA
70805-3823
US

IV. Provider business mailing address

4824 E BROOKSTOWN DR
BATON ROUGE LA
70805-3823
US

V. Phone/Fax

Practice location:
  • Phone: 225-357-7206
  • Fax: 225-357-6424
Mailing address:
  • Phone: 225-357-7206
  • Fax: 225-357-6424

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number7258
License Number StateLA

VIII. Authorized Official

Name: MRS. DOROTHY I NELSON
Title or Position: CEO
Credential:
Phone: 225-357-7206