Provider Demographics
NPI:1003141391
Name:HEAVENLY HEALING INC
Entity Type:Organization
Organization Name:HEAVENLY HEALING INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MISS
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:G
Authorized Official - Last Name:MCMILLIAN
Authorized Official - Suffix:
Authorized Official - Credentials:ADMINISTRATIVE
Authorized Official - Phone:414-940-0465
Mailing Address - Street 1:PO BOX 250394
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53225-6504
Mailing Address - Country:US
Mailing Address - Phone:414-940-0465
Mailing Address - Fax:
Practice Address - Street 1:8225 NORTH 107TH STREET
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53218
Practice Address - Country:US
Practice Address - Phone:727-697-7241
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-05
Last Update Date:2017-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1003141391Medicaid