Provider Demographics
NPI:1326138397
Name:HEAVENLY HEALTHCARE AGENCY, INC.
Entity Type:Organization
Organization Name:HEAVENLY HEALTHCARE AGENCY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:ANTOINETTA
Authorized Official - Middle Name:D
Authorized Official - Last Name:FULTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-230-0808
Mailing Address - Street 1:503 W MCGEE ST
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27401-2702
Mailing Address - Country:US
Mailing Address - Phone:336-230-0808
Mailing Address - Fax:336-230-0842
Practice Address - Street 1:503 W MCGEE ST
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27401-2702
Practice Address - Country:US
Practice Address - Phone:336-230-0808
Practice Address - Fax:336-230-0842
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHC2337374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6600937Medicaid
NC3409611Medicaid