Provider Demographics
NPI:1417135765
Name:HEAVEN ASSISTED LIVING FACILITY
Entity Type:Organization
Organization Name:HEAVEN ASSISTED LIVING FACILITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JUANA
Authorized Official - Middle Name:MARIA
Authorized Official - Last Name:PACHECO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-263-1274
Mailing Address - Street 1:30136 SW 148TH PL
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33033-3835
Mailing Address - Country:US
Mailing Address - Phone:305-245-2290
Mailing Address - Fax:
Practice Address - Street 1:30136 SW 148TH PL
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33033-3835
Practice Address - Country:US
Practice Address - Phone:305-245-2290
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-07
Last Update Date:2008-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL11193310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility