Provider Demographics
NPI:1174958474
Name:HEAVENLY ANGEL WINGS RETIREMENT HOME
Entity type:Organization
Organization Name:HEAVENLY ANGEL WINGS RETIREMENT HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:CRAWHORN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-250-4051
Mailing Address - Street 1:8404 KNIFLEY RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:KY
Mailing Address - Zip Code:42728-7505
Mailing Address - Country:US
Mailing Address - Phone:270-250-4051
Mailing Address - Fax:
Practice Address - Street 1:8404 KNIFLEY RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:KY
Practice Address - Zip Code:42728-7505
Practice Address - Country:US
Practice Address - Phone:270-250-4051
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-05
Last Update Date:2013-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY320700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities