Provider Demographics
NPI:1154094423
Name:DELORES HEAVENLY GATES
Entity Type:Organization
Organization Name:DELORES HEAVENLY GATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TARA
Authorized Official - Middle Name:
Authorized Official - Last Name:GHOLSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-598-2819
Mailing Address - Street 1:19974 GREENFIELD RD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48235-1801
Mailing Address - Country:US
Mailing Address - Phone:313-598-2819
Mailing Address - Fax:313-846-4001
Practice Address - Street 1:19974 GREENFIELD RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48235-1801
Practice Address - Country:US
Practice Address - Phone:313-598-2819
Practice Address - Fax:313-846-4001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-31
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care