Provider Demographics
NPI:1114342169
Name:HEAVENLY SOLES PLLC
Entity Type:Organization
Organization Name:HEAVENLY SOLES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIE
Authorized Official - Middle Name:C
Authorized Official - Last Name:PAUL
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:623-584-0760
Mailing Address - Street 1:13954 W WADDELL RD
Mailing Address - Street 2:SUITE 307
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85379-8750
Mailing Address - Country:US
Mailing Address - Phone:623-584-0760
Mailing Address - Fax:623-546-0344
Practice Address - Street 1:13954 W WADDELL RD
Practice Address - Street 2:SUITE 307
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85379-8750
Practice Address - Country:US
Practice Address - Phone:623-584-0760
Practice Address - Fax:623-546-0344
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-27
Last Update Date:2016-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0711213EP1101X, 261QP1100X, 3104A0630X, 311500000X, 311ZA0620X, 313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Single Specialty
No261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
No3104A0630XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Behavioral Disturbances
No311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)
No311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care FacilityGroup - Single Specialty