Provider Demographics
NPI:1275792327
Name:ANGEL STAR OF DURHAM
Entity Type:Organization
Organization Name:ANGEL STAR OF DURHAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:VERONICA
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCLENDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:740-549-1659
Mailing Address - Street 1:110 SCOTT AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:HIGH POINT
Mailing Address - State:NC
Mailing Address - Zip Code:27262-7834
Mailing Address - Country:US
Mailing Address - Phone:336-889-3372
Mailing Address - Fax:336-889-3371
Practice Address - Street 1:110 SCOTT AVE
Practice Address - Street 2:SUITE A
Practice Address - City:HIGH POINT
Practice Address - State:NC
Practice Address - Zip Code:27262-7834
Practice Address - Country:US
Practice Address - Phone:336-889-3372
Practice Address - Fax:336-889-3371
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ASD HIGHPOINTII
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-06-04
Last Update Date:2008-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHC1481251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6601776Medicaid