Provider Demographics
NPI:1093994683
Name:HEAVENLY EMBRACE
Entity Type:Organization
Organization Name:HEAVENLY EMBRACE
Other - Org Name:MITCHELL BROWN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/ FACILITY DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MITCHELL
Authorized Official - Middle Name:KENDELL
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-723-4776
Mailing Address - Street 1:353 JONESTOWN RD # 127
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27104-4620
Mailing Address - Country:US
Mailing Address - Phone:336-723-4776
Mailing Address - Fax:336-734-1656
Practice Address - Street 1:806 GREEN VALLEY RD STE 307
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27408-7076
Practice Address - Country:US
Practice Address - Phone:336-723-4776
Practice Address - Fax:336-734-1656
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-30
Last Update Date:2007-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health