Provider Demographics
NPI:1184851453
Name:HEAVEN-ON-EARTH NETWORK OF MAMOU, LLC
Entity Type:Organization
Organization Name:HEAVEN-ON-EARTH NETWORK OF MAMOU, LLC
Other - Org Name:HEAVEN-ON-EARTH NETWORK, INC.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MYRON
Authorized Official - Middle Name:CORDELL
Authorized Official - Last Name:GUILLORY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:434-229-4962
Mailing Address - Street 1:1321 4TH STREET
Mailing Address - Street 2:
Mailing Address - City:MAMOU
Mailing Address - State:LA
Mailing Address - Zip Code:70554
Mailing Address - Country:US
Mailing Address - Phone:337-468-2730
Mailing Address - Fax:337-468-2782
Practice Address - Street 1:1321 4TH STREET
Practice Address - Street 2:
Practice Address - City:MAMOU
Practice Address - State:LA
Practice Address - Zip Code:70554
Practice Address - Country:US
Practice Address - Phone:337-468-2730
Practice Address - Fax:337-468-2782
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-15
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA20161253Z00000X
LA15227253Z00000X
372500000X, 372600000X, 3747A0650X, 3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes372600000XNursing Service Related ProvidersAdult CompanionGroup - Multi-Specialty
No253Z00000XAgenciesIn Home Supportive Care
No372500000XNursing Service Related ProvidersChore ProviderGroup - Multi-Specialty
No3747A0650XNursing Service Related ProvidersTechnicianAttendant Care ProviderGroup - Multi-Specialty
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2544977Medicaid
LA1882704Medicaid
LA1460893Medicaid
LA1882712Medicaid
LA1171336Medicaid
LA1435121Medicaid
LA1882691Medicaid