MEDICARE: HEAVENLY ADULT CARE 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	310400000X	Assisted Living Facility	13020	FL

General Provider Information

NPI Number	:	1659857001
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HEAVENLY ADULT CARE LLC

Provider Business Mailing Address
First Line	:	3934 SW KAKOPO ST
Second Line	:
City	:	PORT ST LUCIE
State	:	FL
Zip	:	34953-3631
Country	:	US
Telephone Number	:	772-626-9539
Fax Number	:

Provider Business Practice Location Address
First Line	:	3934 SW KAKOPO ST
Second Line	:
City	:	PORT ST LUCIE
State	:	FL
Zip	:	34953-3631
Country	:	US
Telephone Number	:	772-626-9539
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MS. SONIA REID
Credential	:	RN
Telephone Number	:	772-626-9539

Provider Enumeration Date	:	07/18/2018
Last Update Date	:	07/18/2018

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