Provider Demographics
NPI:1942561717
Name:HEAVENLY ANGELS HOME OF CARE PCH, LLC
Entity Type:Organization
Organization Name:HEAVENLY ANGELS HOME OF CARE PCH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:AYANNA
Authorized Official - Middle Name:R
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-361-8485
Mailing Address - Street 1:5369 SAND BAR LN
Mailing Address - Street 2:
Mailing Address - City:COLLEGE PARK
Mailing Address - State:GA
Mailing Address - Zip Code:30349-3058
Mailing Address - Country:US
Mailing Address - Phone:404-361-8485
Mailing Address - Fax:404-393-9382
Practice Address - Street 1:5530 SWANSON RD
Practice Address - Street 2:
Practice Address - City:ELLENWOOD
Practice Address - State:GA
Practice Address - Zip Code:30294-3857
Practice Address - Country:US
Practice Address - Phone:404-361-8485
Practice Address - Fax:404-393-9382
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-07
Last Update Date:2012-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPCH006734320600000X, 320700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
No320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities