Provider Demographics
NPI:1447497425
Name:HEAVENLY MEDICAL SUPPLY
Entity type:Organization
Organization Name:HEAVENLY MEDICAL SUPPLY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL SUPPLIER
Authorized Official - Prefix:
Authorized Official - First Name:CLAUDIA
Authorized Official - Middle Name:DENICE
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-283-1210
Mailing Address - Street 1:6349 ESTATES DR
Mailing Address - Street 2:
Mailing Address - City:BASTROP
Mailing Address - State:LA
Mailing Address - Zip Code:71220-9749
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6349 ESTATES DR
Practice Address - Street 2:
Practice Address - City:BASTROP
Practice Address - State:LA
Practice Address - Zip Code:71220-9749
Practice Address - Country:US
Practice Address - Phone:318-283-1210
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-13
Last Update Date:2009-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities