Provider Demographics
NPI:1467812941
Name:ANGEL'S INN
Entity Type:Organization
Organization Name:ANGEL'S INN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:FLOYD
Authorized Official - Middle Name:AUSTIN
Authorized Official - Last Name:BRADLEY
Authorized Official - Suffix:
Authorized Official - Credentials:LHNA
Authorized Official - Phone:315-782-2238
Mailing Address - Street 1:518 PINE ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-3235
Mailing Address - Country:US
Mailing Address - Phone:315-782-2238
Mailing Address - Fax:
Practice Address - Street 1:518 PINE ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-3235
Practice Address - Country:US
Practice Address - Phone:315-782-2238
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-26
Last Update Date:2016-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY330F036311ZA0620X
NY05684376G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care HomeGroup - Single Specialty
No376G00000XNursing Service Related ProvidersNursing Home AdministratorGroup - Single Specialty