=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902397854
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HEAVENLY HANDS ASSISTED LIVING, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/27/2018
-----------------------------------------------------
Last Update Date | 05/27/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1909 NW 12TH AVE
-----------------------------------------------------
City | CAPE CORAL
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33993-3971
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-346-1292
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1909 NW 12TH AVE
-----------------------------------------------------
City | CAPE CORAL
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33993-3971
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-691-0686
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MR. WILLIAM LEROY WILCOX JR.
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 239-691-0686
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | 13175
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------