Provider Demographics
NPI:1962828103
Name:HEAVENLY HEALTH SERVICES LLC
Entity Type:Organization
Organization Name:HEAVENLY HEALTH SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROPRIATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:EVA
Authorized Official - Middle Name:MIREILLE
Authorized Official - Last Name:JACQUES
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:954-673-4065
Mailing Address - Street 1:388 SW 163RD AVE
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33027-1084
Mailing Address - Country:US
Mailing Address - Phone:954-673-4065
Mailing Address - Fax:
Practice Address - Street 1:388 SW 163RD AVE
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33027-1084
Practice Address - Country:US
Practice Address - Phone:954-673-4065
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-12
Last Update Date:2014-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL3082172363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty