Provider Demographics
NPI:1750956744
Name:HEAVENLY CARE LLC
Entity type:Organization
Organization Name:HEAVENLY CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:KANOBAYITA
Authorized Official - Middle Name:
Authorized Official - Last Name:DORIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-316-1347
Mailing Address - Street 1:3129 W ACAPULCO LN
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85053-4885
Mailing Address - Country:US
Mailing Address - Phone:601-316-1347
Mailing Address - Fax:
Practice Address - Street 1:3129 W ACAPULCO LN
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85053-4885
Practice Address - Country:US
Practice Address - Phone:601-316-1347
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-24
Last Update Date:2023-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ092973Medicaid