Provider Demographics
NPI:1962858878
Name:HEAVEN BOUND LIFESTYLE CENTER
Entity Type:Organization
Organization Name:HEAVEN BOUND LIFESTYLE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:GOODWIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:775-219-5679
Mailing Address - Street 1:PO BOX 3527
Mailing Address - Street 2:
Mailing Address - City:SPARKS
Mailing Address - State:NV
Mailing Address - Zip Code:89432-3527
Mailing Address - Country:US
Mailing Address - Phone:775-219-5679
Mailing Address - Fax:
Practice Address - Street 1:7551 YOUNG CIR
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89511-1337
Practice Address - Country:US
Practice Address - Phone:775-219-5679
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-10
Last Update Date:2016-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
385H00000X
NV385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV9005048283Medicaid