Provider Demographics
NPI:1114549763
Name:IDELLA'S ANGELS
Entity Type:Organization
Organization Name:IDELLA'S ANGELS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:LAVERNE
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-200-4887
Mailing Address - Street 1:270 13TH AVE SW
Mailing Address - Street 2:
Mailing Address - City:CAIRO
Mailing Address - State:GA
Mailing Address - Zip Code:39828-3423
Mailing Address - Country:US
Mailing Address - Phone:229-200-4887
Mailing Address - Fax:
Practice Address - Street 1:270 13TH AVE SW
Practice Address - Street 2:
Practice Address - City:CAIRO
Practice Address - State:GA
Practice Address - Zip Code:39828-3423
Practice Address - Country:US
Practice Address - Phone:229-200-4887
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-16
Last Update Date:2021-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
No291U00000XLaboratoriesClinical Medical Laboratory