Healthcare Provider Details

I. General information

NPI: 1457842585
Provider Name (Legal Business Name): HEAVEN SENT FOOT HEALTHCARE, PLCC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2018
Last Update Date: 05/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

160 CYPRESS STREET
TCHULA MS
39169
US

IV. Provider business mailing address

PO BOX 572
TCHULA MS
39169-0572
US

V. Phone/Fax

Practice location:
  • Phone: 662-670-4197
  • Fax:
Mailing address:
  • Phone: 662-670-4197
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number894906
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number894906
License Number StateMS

VIII. Authorized Official

Name: DEALICE NIKITA YOUNG
Title or Position: RN/CEO
Credential: RN
Phone: 662-670-4197