Provider Demographics
NPI:1356783229
Name:HEAVENLY PLACE LLC
Entity type:Organization
Organization Name:HEAVENLY PLACE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JULIET
Authorized Official - Middle Name:
Authorized Official - Last Name:OKWOSHAH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-819-3882
Mailing Address - Street 1:PO BOX 41153
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27629-1153
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8600 NEUSE HUNTER DR
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27616-7735
Practice Address - Country:US
Practice Address - Phone:919-819-3882
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-21
Last Update Date:2013-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-092-866320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities