Provider Demographics
NPI:1083126346
Name:ANGELIC PLACE LLC
Entity Type:Organization
Organization Name:ANGELIC PLACE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RESIDENTIAL DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:EMIGDUS
Authorized Official - Middle Name:
Authorized Official - Last Name:NKEM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:571-494-7066
Mailing Address - Street 1:5500 SILVER MAPLE LN
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22407-9357
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8108 CHERRY TREE DR
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22407-7344
Practice Address - Country:US
Practice Address - Phone:571-494-7066
Practice Address - Fax:571-494-7066
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-26
Last Update Date:2017-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA=========Medicaid