Provider Demographics
NPI:1457842585
Name:HEAVEN SENT FOOT HEALTHCARE, PLCC
Entity Type:Organization
Organization Name:HEAVEN SENT FOOT HEALTHCARE, PLCC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RN/CEO
Authorized Official - Prefix:
Authorized Official - First Name:DEALICE
Authorized Official - Middle Name:NIKITA
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:662-670-4197
Mailing Address - Street 1:PO BOX 572
Mailing Address - Street 2:
Mailing Address - City:TCHULA
Mailing Address - State:MS
Mailing Address - Zip Code:39169-0572
Mailing Address - Country:US
Mailing Address - Phone:662-670-4197
Mailing Address - Fax:
Practice Address - Street 1:160 CYPRESS STREET
Practice Address - Street 2:
Practice Address - City:TCHULA
Practice Address - State:MS
Practice Address - Zip Code:39169
Practice Address - Country:US
Practice Address - Phone:662-670-4197
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-24
Last Update Date:2018-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS894906163W00000X, 251J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty
No251J00000XAgenciesNursing CareGroup - Single Specialty