Provider Demographics
NPI:1124145347
Name:HEAVEN SENT ISL
Entity type:Organization
Organization Name:HEAVEN SENT ISL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:DAMARA
Authorized Official - Middle Name:
Authorized Official - Last Name:GAINES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-886-2191
Mailing Address - Street 1:3001 YUKON DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65202-0922
Mailing Address - Country:US
Mailing Address - Phone:573-886-2191
Mailing Address - Fax:
Practice Address - Street 1:3001 YUKON DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65202-0922
Practice Address - Country:US
Practice Address - Phone:573-886-2191
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-23
Last Update Date:2008-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1982-8946251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health