Provider Demographics
NPI:1770005837
Name:HEAVENLY IN HOMECARE LLC
Entity Type:Organization
Organization Name:HEAVENLY IN HOMECARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CHARLENE
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-274-2368
Mailing Address - Street 1:109 E DONALD ST STE 8
Mailing Address - Street 2:
Mailing Address - City:QUITMAN
Mailing Address - State:MS
Mailing Address - Zip Code:39355-2310
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:109 E DONALD ST STE 8
Practice Address - Street 2:
Practice Address - City:QUITMAN
Practice Address - State:MS
Practice Address - Zip Code:39355-2310
Practice Address - Country:US
Practice Address - Phone:601-274-2368
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-11
Last Update Date:2017-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05Medicaid