Provider Demographics
NPI:1396173159
Name:HEAVENLY SUNSHINE HEALTH
Entity type:Organization
Organization Name:HEAVENLY SUNSHINE HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:SABINA
Authorized Official - Middle Name:
Authorized Official - Last Name:GRESHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-549-2289
Mailing Address - Street 1:975 GAINES SCHOOL RD # BUILD-4
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30605-3133
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:975 GAINES SCHOOL RD # BUILD-4
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30605-3133
Practice Address - Country:US
Practice Address - Phone:706-549-2289
Practice Address - Fax:706-549-1177
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-14
Last Update Date:2013-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA109-R-0323251J00000X, 376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376K00000XNursing Service Related ProvidersNurse's AideGroup - Single Specialty
No251J00000XAgenciesNursing Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA896062924BMedicaid
GA896062924DMedicaid
GA896062924EMedicaid
GA896062924AMedicaid
GA003132295AMedicaid