Provider Demographics
NPI:1881049070
Name:HEAVENLY HOME HEALTHCARE AGENCY LLC
Entity type:Organization
Organization Name:HEAVENLY HOME HEALTHCARE AGENCY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANGER/SUPERVISIOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:FLORA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:HUDGINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-571-6479
Mailing Address - Street 1:1032 ADRIAN ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49203-3204
Mailing Address - Country:US
Mailing Address - Phone:231-571-6479
Mailing Address - Fax:517-789-7559
Practice Address - Street 1:1032 ADRIAN ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49203-3204
Practice Address - Country:US
Practice Address - Phone:231-571-6479
Practice Address - Fax:517-789-7559
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-26
Last Update Date:2016-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health