Provider Demographics
NPI:1679856629
Name:ANGELS CORNER LL
Entity Type:Organization
Organization Name:ANGELS CORNER LL
Other - Org Name:ANGELS CORNER L
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:JOANNE
Authorized Official - Middle Name:B
Authorized Official - Last Name:MIMS
Authorized Official - Suffix:
Authorized Official - Credentials:COUNSELOR
Authorized Official - Phone:478-750-7747
Mailing Address - Street 1:279 HAMPTON RD S
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31217-8536
Mailing Address - Country:US
Mailing Address - Phone:478-750-7747
Mailing Address - Fax:478-750-7747
Practice Address - Street 1:279 HAMPTON RD S
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31217-8536
Practice Address - Country:US
Practice Address - Phone:478-750-7747
Practice Address - Fax:478-750-7747
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-27
Last Update Date:2011-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM0850X, 311ZA0620X
GA25896382261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home