=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386183952
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HEAVENLY CREATIONS IN HOME CARE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/16/2017
-----------------------------------------------------
Last Update Date | 02/16/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1615 APPLE VALLEY DR
-----------------------------------------------------
City | AUGUSTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30906-3859
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-496-3820
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1615 APPLE VALLEY DR
-----------------------------------------------------
City | AUGUSTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30906-3859
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-496-3820
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MRS. FRANKIE FERGUSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 706-496-3820
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------