Provider Demographics
NPI:1275271579
Name:ANGEL LEAF HOME CARE PROVIDERS
Entity Type:Organization
Organization Name:ANGEL LEAF HOME CARE PROVIDERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OCCUPATIONAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:EDNA
Authorized Official - Middle Name:
Authorized Official - Last Name:LUCIO
Authorized Official - Suffix:
Authorized Official - Credentials:OTR
Authorized Official - Phone:979-418-7165
Mailing Address - Street 1:337 SHERI LN
Mailing Address - Street 2:
Mailing Address - City:LAKE JACKSON
Mailing Address - State:TX
Mailing Address - Zip Code:77566-3269
Mailing Address - Country:US
Mailing Address - Phone:979-418-7165
Mailing Address - Fax:
Practice Address - Street 1:309 PLANTATION DR
Practice Address - Street 2:
Practice Address - City:LAKE JACKSON
Practice Address - State:TX
Practice Address - Zip Code:77566-6142
Practice Address - Country:US
Practice Address - Phone:979-418-7165
Practice Address - Fax:800-419-5153
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-25
Last Update Date:2023-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes253Z00000XAgenciesIn Home Supportive Care
No224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatricsGroup - Multi-Specialty
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX021439OtherAGENCY LICENSE