Provider Demographics
NPI:1023226495
Name:HEAVENLY HOME CARE
Entity type:Organization
Organization Name:HEAVENLY HOME CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER ADMINISTRATOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:SERENA
Authorized Official - Middle Name:FAYE
Authorized Official - Last Name:WAGGONER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-245-0994
Mailing Address - Street 1:5420 E 99TH AVE
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99507-6622
Mailing Address - Country:US
Mailing Address - Phone:907-245-0994
Mailing Address - Fax:
Practice Address - Street 1:5420 E 99TH AVE
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99507-6622
Practice Address - Country:US
Practice Address - Phone:907-245-0994
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-18
Last Update Date:2008-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK000258310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKRL97411Medicaid