Provider Demographics
NPI:1083730055
Name:HEAVENLY TOUCH CARE HOME
Entity Type:Organization
Organization Name:HEAVENLY TOUCH CARE HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ARCHIE
Authorized Official - Middle Name:
Authorized Official - Last Name:CROCKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-739-6429
Mailing Address - Street 1:429 CROCKER RD
Mailing Address - Street 2:
Mailing Address - City:KINGS MOUNTAIN
Mailing Address - State:NC
Mailing Address - Zip Code:28086-4004
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:429 CROCKER RD
Practice Address - Street 2:
Practice Address - City:KINGS MOUNTAIN
Practice Address - State:NC
Practice Address - Zip Code:28086-4004
Practice Address - Country:US
Practice Address - Phone:704-739-6429
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-22
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCFCL 023-010310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7801288Medicaid