=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891104105
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HEAVENLY HEALTH CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/12/2014
-----------------------------------------------------
Last Update Date | 08/12/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3242 GLYNN MILL DR NONE
-----------------------------------------------------
City | SNELLVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30039-6235
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-563-2952
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3242 GLYNN MILL DR NONE
-----------------------------------------------------
City | SNELLVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30039-6235
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-563-2952
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MS. LINDA RODRIGUEZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 404-563-2952
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | 2014013840
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------