Provider Demographics
NPI:1891813028
Name:ANGELS FAMILY CARE HOME #4
Entity Type:Organization
Organization Name:ANGELS FAMILY CARE HOME #4
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:GRAVES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-222-9297
Mailing Address - Street 1:210 UNION AVE
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27217-2442
Mailing Address - Country:US
Mailing Address - Phone:336-570-5770
Mailing Address - Fax:336-228-9376
Practice Address - Street 1:210 UNION AVE
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27217-2442
Practice Address - Country:US
Practice Address - Phone:336-570-5770
Practice Address - Fax:336-228-9376
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-001-113311Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311Z00000XNursing & Custodial Care FacilitiesCustodial Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7804934Medicaid