MEDICARE: HEAVENLY ANGELS CARE 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	251J00000X	Nursing Care Agency

General Provider Information

NPI Number	:	1609645787
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HEAVENLY ANGELS CARE HOME LLC

Provider Business Mailing Address
First Line	:	1414 E PASEO WAY # B
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85042-8405
Country	:	US
Telephone Number	:	480-206-9219
Fax Number	:

Provider Business Practice Location Address
First Line	:	1414 E PASEO WAY # A
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85042-8405
Country	:	US
Telephone Number	:	480-206-9219
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MS. SHAHIDAH F MOORE
Credential	:
Telephone Number	:	480-206-9219

Provider Enumeration Date	:	12/29/2023
Last Update Date	:	12/29/2023

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