Provider Demographics
NPI:1417511775
Name:AGAPE WINGS LLC
Entity Type:Organization
Organization Name:AGAPE WINGS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHARMIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:AKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-363-4592
Mailing Address - Street 1:1715 NE 8TH AVE APT I4
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32641-4765
Mailing Address - Country:US
Mailing Address - Phone:352-363-4592
Mailing Address - Fax:
Practice Address - Street 1:1715 NE 8TH AVE APT I4
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32641-4765
Practice Address - Country:US
Practice Address - Phone:352-363-4592
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-23
Last Update Date:2019-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL740539Medicaid