Provider Demographics
NPI:1316414287
Name:A HEAVENLY HOME, LLC
Entity Type:Organization
Organization Name:A HEAVENLY HOME, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:CHARICE
Authorized Official - Middle Name:V
Authorized Official - Last Name:DUCTANT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-332-5034
Mailing Address - Street 1:21135 NW 14TH PL APT 157
Mailing Address - Street 2:
Mailing Address - City:MIAMI GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33169-2941
Mailing Address - Country:US
Mailing Address - Phone:305-332-5034
Mailing Address - Fax:
Practice Address - Street 1:1046-1048 NW 8TH AVE
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33311-3331
Practice Address - Country:US
Practice Address - Phone:305-332-5034
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-30
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness