Provider Demographics
NPI:1093416497
Name:HEAVENLY MANOR LLC
Entity Type:Organization
Organization Name:HEAVENLY MANOR LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHAMECKA
Authorized Official - Middle Name:LAWANDA
Authorized Official - Last Name:DINKINS
Authorized Official - Suffix:
Authorized Official - Credentials:RN, MSN
Authorized Official - Phone:757-771-1477
Mailing Address - Street 1:132 BURNS ST
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23669-4610
Mailing Address - Country:US
Mailing Address - Phone:757-771-1477
Mailing Address - Fax:
Practice Address - Street 1:132 BURNS ST
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23669-4610
Practice Address - Country:US
Practice Address - Phone:757-771-1477
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-13
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172V00000XOther Service ProvidersCommunity Health WorkerGroup - Single Specialty