Provider Demographics
NPI:1932461571
Name:HEAVENLY CIRCLE LIMITED LIABILITY COMPANY
Entity Type:Organization
Organization Name:HEAVENLY CIRCLE LIMITED LIABILITY COMPANY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:C.E.O
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARILYN
Authorized Official - Middle Name:
Authorized Official - Last Name:VICENTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:440-396-3246
Mailing Address - Street 1:502 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:LORAIN
Mailing Address - State:OH
Mailing Address - Zip Code:44052-1732
Mailing Address - Country:US
Mailing Address - Phone:440-282-8022
Mailing Address - Fax:440-282-8024
Practice Address - Street 1:502 BROADWAY
Practice Address - Street 2:
Practice Address - City:LORAIN
Practice Address - State:OH
Practice Address - Zip Code:44052-1732
Practice Address - Country:US
Practice Address - Phone:440-282-8022
Practice Address - Fax:440-282-8024
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-11
Last Update Date:2019-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0076229Medicaid