Healthcare Provider Details

I. General information

NPI: 1427118926
Provider Name (Legal Business Name): HEAVENLY HEALTH INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 11/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

308 EAST HILL AVENUE
GALLUP NM
87301
US

IV. Provider business mailing address

308 EAST HILL AVENUE
GALLUP NM
87301
US

V. Phone/Fax

Practice location:
  • Phone: 505-722-6770
  • Fax: 505-722-6799
Mailing address:
  • Phone: 505-722-6770
  • Fax: 505-722-6799

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: GEORGES DUVAL
Title or Position: VICE PRESIDENT
Credential: MD
Phone: 505-722-6770