Provider Demographics
NPI:1497293559
Name:ANGEL WING RESIDENTIAL CARE HOME
Entity Type:Organization
Organization Name:ANGEL WING RESIDENTIAL CARE HOME
Other - Org Name:RESIDENTIAL CARE HOME
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:WALLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-349-6916
Mailing Address - Street 1:803 FLOYD AVE
Mailing Address - Street 2:
Mailing Address - City:DEMOPOLIS
Mailing Address - State:AL
Mailing Address - Zip Code:36732-3157
Mailing Address - Country:US
Mailing Address - Phone:334-349-6916
Mailing Address - Fax:
Practice Address - Street 1:803 FLOYD AVE
Practice Address - Street 2:
Practice Address - City:DEMOPOLIS
Practice Address - State:AL
Practice Address - Zip Code:36732-3157
Practice Address - Country:US
Practice Address - Phone:334-349-6916
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-08
Last Update Date:2017-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities