Provider Demographics
NPI:1043592496
Name:ANGEL WINGS ASSISTED LIVING, INC
Entity Type:Organization
Organization Name:ANGEL WINGS ASSISTED LIVING, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AUDREY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:FELIX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-242-5517
Mailing Address - Street 1:PO BOX 339
Mailing Address - Street 2:
Mailing Address - City:VERNON
Mailing Address - State:AZ
Mailing Address - Zip Code:85940-0339
Mailing Address - Country:US
Mailing Address - Phone:928-242-5517
Mailing Address - Fax:877-581-4791
Practice Address - Street 1:86 ACR 3148
Practice Address - Street 2:
Practice Address - City:VERNON
Practice Address - State:AZ
Practice Address - Zip Code:85940
Practice Address - Country:US
Practice Address - Phone:928-242-5517
Practice Address - Fax:877-581-4791
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-12
Last Update Date:2012-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ657171Medicaid
AZAL8533HOtherDHS