MEDICARE: HEAVENLY HOME HEALTHCARE AGENCY 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	251E00000X	Home Health Agency		MI

General Provider Information

NPI Number	:	1881049070
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HEAVENLY HOME HEALTHCARE AGENCY LLC

Provider Business Mailing Address
First Line	:	1032 ADRIAN ST
Second Line	:
City	:	JACKSON
State	:	MI
Zip	:	49203-3204
Country	:	US
Telephone Number	:	231-571-6479
Fax Number	:	517-789-7559

Provider Business Practice Location Address
First Line	:	1032 ADRIAN ST
Second Line	:
City	:	JACKSON
State	:	MI
Zip	:	49203-3204
Country	:	US
Telephone Number	:	231-571-6479
Fax Number	:	517-789-7559

Authorized Official
Title or Position	:	MANGER/SUPERVISIOR
Name	:	MRS. FLORA ANN HUDGINS
Credential	:
Telephone Number	:	231-571-6479

Provider Enumeration Date	:	04/26/2016
Last Update Date	:	04/26/2016

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