Provider Demographics
NPI:1780211284
Name:ANGEL HEART HOSPICE AND PALLIATIVE CARE MOBILE LAB
Entity Type:Organization
Organization Name:ANGEL HEART HOSPICE AND PALLIATIVE CARE MOBILE LAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DWELVER
Authorized Official - Middle Name:NIKKI
Authorized Official - Last Name:WEBB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:470-381-2983
Mailing Address - Street 1:2302 PARKLAKE DR NE STE 568
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30345-2896
Mailing Address - Country:US
Mailing Address - Phone:470-381-2139
Mailing Address - Fax:
Practice Address - Street 1:2302 PARKLAKE DR NE # 568
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30345-2896
Practice Address - Country:US
Practice Address - Phone:470-381-2983
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HOSPICE CARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-03-25
Last Update Date:2022-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251G00000XAgenciesHospice Care, Community Based
No247ZC0005XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyClinical Laboratory Director, Non-physicianGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1780211284Medicaid