Provider Demographics
NPI:1710619721
Name:ANGELS WITH BROKEN WINGS
Entity Type:Organization
Organization Name:ANGELS WITH BROKEN WINGS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GINGER
Authorized Official - Middle Name:
Authorized Official - Last Name:SHANNON
Authorized Official - Suffix:
Authorized Official - Credentials:CPSW
Authorized Official - Phone:575-288-8766
Mailing Address - Street 1:PO BOX 14291
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88013-4291
Mailing Address - Country:US
Mailing Address - Phone:575-288-8766
Mailing Address - Fax:
Practice Address - Street 1:1705 E GRIGGS AVE
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88001-2644
Practice Address - Country:US
Practice Address - Phone:575-288-8766
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-28
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes177F00000XOther Service ProvidersLodging