Provider Demographics
NPI:1497962575
Name:ANGEL WINGS CENTER OF HEALING
Entity Type:Organization
Organization Name:ANGEL WINGS CENTER OF HEALING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER-MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:BOBETTE
Authorized Official - Middle Name:R
Authorized Official - Last Name:PAGE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:208-757-0330
Mailing Address - Street 1:477 SHOUP AVE STE 107B
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83402-3658
Mailing Address - Country:US
Mailing Address - Phone:208-522-1914
Mailing Address - Fax:208-522-1956
Practice Address - Street 1:477 SHOUP AVE STE 107B
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402-3658
Practice Address - Country:US
Practice Address - Phone:208-522-1914
Practice Address - Fax:208-522-1956
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-17
Last Update Date:2007-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-27373251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health