Provider Demographics
NPI:1639480346
Name:ANGEL'S GROUP HOME, LLC
Entity Type:Organization
Organization Name:ANGEL'S GROUP HOME, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:VALARIE
Authorized Official - Middle Name:CONSTANCE
Authorized Official - Last Name:MCCULLERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-963-9167
Mailing Address - Street 1:10590 CLEVELAND ROAD
Mailing Address - Street 2:
Mailing Address - City:GARNER
Mailing Address - State:NC
Mailing Address - Zip Code:27529
Mailing Address - Country:US
Mailing Address - Phone:919-963-9167
Mailing Address - Fax:919-963-9168
Practice Address - Street 1:10590 CLEVELAND RD
Practice Address - Street 2:
Practice Address - City:GARNER
Practice Address - State:NC
Practice Address - Zip Code:27529-8187
Practice Address - Country:US
Practice Address - Phone:919-963-9167
Practice Address - Fax:919-963-9168
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-28
Last Update Date:2010-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities