Provider Demographics
NPI:1306020169
Name:ANGEL ASSISTED LIVING
Entity Type:Organization
Organization Name:ANGEL ASSISTED LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ANGELINA
Authorized Official - Middle Name:S
Authorized Official - Last Name:UGHIOVHE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-577-2999
Mailing Address - Street 1:8919 HICKORY HILL AVE
Mailing Address - Street 2:
Mailing Address - City:LANHAM
Mailing Address - State:MD
Mailing Address - Zip Code:20706-2851
Mailing Address - Country:US
Mailing Address - Phone:301-577-2999
Mailing Address - Fax:301-577-3771
Practice Address - Street 1:8919 HICKORY HILL AVE
Practice Address - Street 2:
Practice Address - City:LANHAM
Practice Address - State:MD
Practice Address - Zip Code:20706-2851
Practice Address - Country:US
Practice Address - Phone:301-577-2999
Practice Address - Fax:301-577-3771
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-28
Last Update Date:2007-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD16ALO745310400000X
MD16AL0794310400000X
MD16AL454310400000X
MD16AL0843310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD0026425-02Medicaid
MD989401200Medicaid
MD989401201Medicaid
MD002642501Medicaid