Provider Demographics
NPI:1669664082
Name:A HEAVENLY HOME HEALTHCARE AGENCY
Entity Type:Organization
Organization Name:A HEAVENLY HOME HEALTHCARE AGENCY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:KIMBERLY
Authorized Official - Last Name:STARKS
Authorized Official - Suffix:
Authorized Official - Credentials:BS
Authorized Official - Phone:614-917-9118
Mailing Address - Street 1:430 COURTRIGHT DR
Mailing Address - Street 2:
Mailing Address - City:PICKERINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:43147-1528
Mailing Address - Country:US
Mailing Address - Phone:614-917-9118
Mailing Address - Fax:
Practice Address - Street 1:430 COURTRIGHT DR
Practice Address - Street 2:
Practice Address - City:PICKERINGTON
Practice Address - State:OH
Practice Address - Zip Code:43147-1528
Practice Address - Country:US
Practice Address - Phone:614-917-9118
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-10
Last Update Date:2007-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2531906251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2531906OtherODMRDD CONTRACT NUMBER
OH2743188OtherODJFS MEDICAID PROVIDER #