Provider Demographics
NPI:1154063345
Name:MINK ANGEL LLC
Entity Type:Organization
Organization Name:MINK ANGEL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:RACHELLE
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:267-408-7984
Mailing Address - Street 1:171 W SEYMOUR ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19144-3661
Mailing Address - Country:US
Mailing Address - Phone:126-740-8798
Mailing Address - Fax:
Practice Address - Street 1:5631 N 16TH ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19141-1710
Practice Address - Country:US
Practice Address - Phone:267-627-4740
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-08
Last Update Date:2022-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case ManagementGroup - Single Specialty
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty