Provider Demographics
NPI:1659857001
Name:HEAVENLY ADULT CARE LLC
Entity type:Organization
Organization Name:HEAVENLY ADULT CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SONIA
Authorized Official - Middle Name:
Authorized Official - Last Name:REID
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:772-626-9539
Mailing Address - Street 1:3934 SW KAKOPO ST
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-3631
Mailing Address - Country:US
Mailing Address - Phone:772-626-9539
Mailing Address - Fax:
Practice Address - Street 1:3934 SW KAKOPO ST
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34953-3631
Practice Address - Country:US
Practice Address - Phone:772-626-9539
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-18
Last Update Date:2018-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL13020310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility