Provider Demographics
NPI:1962193938
Name:HEAVENLY CARE LLC
Entity type:Organization
Organization Name:HEAVENLY CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
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 1:6513 W CARIBBEAN LN
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85306-3152
Mailing Address - Country:US
Mailing Address - Phone:601-316-1347
Mailing Address - Fax:
Practice Address - Street 1:6984 W CAVALIER DR
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85303-4435
Practice Address - Country:US
Practice Address - Phone:160-131-6347
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-18
Last Update Date:2023-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health