Provider Demographics
NPI:1417620212
Name:ANGEL GATE HEALTH SERVICES LLC
Entity Type:Organization
Organization Name:ANGEL GATE HEALTH SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:BESONG
Authorized Official - Suffix:
Authorized Official - Credentials:DNP
Authorized Official - Phone:240-491-2868
Mailing Address - Street 1:12403 HATCHWAY CT
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192-2114
Mailing Address - Country:US
Mailing Address - Phone:240-491-2868
Mailing Address - Fax:
Practice Address - Street 1:12403 HATCHWAY CT
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-2114
Practice Address - Country:US
Practice Address - Phone:240-491-2868
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-28
Last Update Date:2021-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA4397Medicaid