Provider Demographics
NPI:1912168568
Name:HEAVENLY HEALTHCARE AGENCY INC
Entity type:Organization
Organization Name:HEAVENLY HEALTHCARE AGENCY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR DIRECTOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:ANTOINETTA
Authorized Official - Middle Name:D
Authorized Official - Last Name:FULTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-230-0808
Mailing Address - Street 1:PO BOX 13531
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27415-3531
Mailing Address - Country:US
Mailing Address - Phone:336-230-0808
Mailing Address - Fax:336-230-0842
Practice Address - Street 1:110 EXCHANGE ST
Practice Address - Street 2:SUITE I
Practice Address - City:DANVILLE
Practice Address - State:VA
Practice Address - Zip Code:24541
Practice Address - Country:US
Practice Address - Phone:434-799-5378
Practice Address - Fax:434-799-5379
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-17
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHC23373747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Single Specialty