MEDICARE: HEAVEN'S ANGELS RESIDENTIAL SERVICES

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	261QM0855X	Adolescent and Children Mental Health Clinic/Center
2	320600000X	Intellectual and/or Developmental Disabilities Residential Treatment Facility	AS820381239	MI
3	320700000X	Physical Disabilities Residential Treatment Facility	AS820381239	MI
4	320800000X	Mental Illness Community Based Residential Treatment Facility
5	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility	AS820381239	MI
6	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
7	174200000X	Meals Provider
8	253Z00000X	In Home Supportive Care Agency
9	261QD1600X	Developmental Disabilities Clinic/Center
10	261QM0850X	Adult Mental Health Clinic/Center
11	385H00000X	Respite Care
12	385HR2055X	Child Mental Illness Respite Care
13	385HR2060X	Child Intellectual and/or Developmental Disabilities Respite Care
14	385HR2065X	Child Physical Disabilities Respite Care
15	320800000X	Mental Illness Community Based Residential Treatment Facility	AS820381239	MI

General Provider Information

NPI Number	:	1740727338
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HEAVEN'S ANGELS RESIDENTIAL SERVICES

Provider Business Mailing Address
First Line	:	12245 BEECH DALY RD
Second Line	:	STE. 40736
City	:	REDFORD
State	:	MI
Zip	:	48240-3200
Country	:	US
Telephone Number	:	734-742-5404
Fax Number	:	888-325-1688

Provider Business Practice Location Address
First Line	:	30120 FORD RD STE C
Second Line	:
City	:	GARDEN CITY
State	:	MI
Zip	:	48135-2396
Country	:	US
Telephone Number	:	734-742-5404
Fax Number	:	888-325-1688

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MS. MIA WHITE
Credential	:
Telephone Number	:	734-742-5404

Provider Enumeration Date	:	01/20/2017
Last Update Date	:	10/21/2020

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