Provider Demographics
NPI:1871912113
Name:HEAVENLY CREATIONS ADULT DAY CARE LLC
Entity type:Organization
Organization Name:HEAVENLY CREATIONS ADULT DAY CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:MAXINE
Authorized Official - Middle Name:R
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:917-226-7249
Mailing Address - Street 1:22008 109TH AVE
Mailing Address - Street 2:
Mailing Address - City:QUEENS VILLAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11429-2515
Mailing Address - Country:US
Mailing Address - Phone:917-226-7249
Mailing Address - Fax:
Practice Address - Street 1:22008 109TH AVE
Practice Address - Street 2:
Practice Address - City:QUEENS VILLAGE
Practice Address - State:NY
Practice Address - Zip Code:11429-2515
Practice Address - Country:US
Practice Address - Phone:917-226-7249
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-15
Last Update Date:2014-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1023377611Medicaid