Provider Demographics
NPI:1205224334
Name:ANGEL'S HOME ICF, INC.
Entity Type:Organization
Organization Name:ANGEL'S HOME ICF, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT / ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:R
Authorized Official - Last Name:ANGEL
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:510-289-3848
Mailing Address - Street 1:10712 WATERBURY DR
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95209-4212
Mailing Address - Country:US
Mailing Address - Phone:510-289-3848
Mailing Address - Fax:209-477-1449
Practice Address - Street 1:10712 WATERBURY DR
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95209-4212
Practice Address - Country:US
Practice Address - Phone:510-289-3848
Practice Address - Fax:209-477-1449
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-23
Last Update Date:2014-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility