MEDICARE: A HEAVENLY HOME, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3104A0625X	Assisted Living Facility (Mental Illness)

General Provider Information

NPI Number	:	1316414287
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	A HEAVENLY HOME, LLC

Provider Business Mailing Address
First Line	:	21135 NW 14TH PL APT 157
Second Line	:
City	:	MIAMI GARDENS
State	:	FL
Zip	:	33169-2941
Country	:	US
Telephone Number	:	305-332-5034
Fax Number	:

Provider Business Practice Location Address
First Line	:	1046-1048 NW 8TH AVE
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33311-3331
Country	:	US
Telephone Number	:	305-332-5034
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MS. CHARICE V DUCTANT
Credential	:
Telephone Number	:	305-332-5034

Provider Enumeration Date	:	10/30/2018
Last Update Date	:	10/30/2018

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