Provider Demographics
NPI:1952051211
Name:1 HEAVENLY DIVINE ADULT FAMILY HOMES LLC
Entity Type:Organization
Organization Name:1 HEAVENLY DIVINE ADULT FAMILY HOMES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-350-3558
Mailing Address - Street 1:PO BOX 16545
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53216-0545
Mailing Address - Country:US
Mailing Address - Phone:414-350-3558
Mailing Address - Fax:414-979-0092
Practice Address - Street 1:4637 N 24TH PL
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53209-6206
Practice Address - Country:US
Practice Address - Phone:414-350-3558
Practice Address - Fax:414-979-0092
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-28
Last Update Date:2022-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home