Provider Demographics
NPI:1831440155
Name:HEAVENLY CHOICE ADULT HOME
Entity type:Organization
Organization Name:HEAVENLY CHOICE ADULT HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:JULIA
Authorized Official - Middle Name:
Authorized Official - Last Name:MORAME
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:863-269-9753
Mailing Address - Street 1:5500 WATKINS RD
Mailing Address - Street 2:
Mailing Address - City:HAINES CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33844-6254
Mailing Address - Country:US
Mailing Address - Phone:863-269-9753
Mailing Address - Fax:
Practice Address - Street 1:5500 WATKINS RD
Practice Address - Street 2:
Practice Address - City:HAINES CITY
Practice Address - State:FL
Practice Address - Zip Code:33844-6254
Practice Address - Country:US
Practice Address - Phone:863-269-9753
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-26
Last Update Date:2012-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL6906270302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000422700Medicaid