Provider Demographics
NPI:1972898542
Name:ANGEL ADULT CENTER 11
Entity Type:Organization
Organization Name:ANGEL ADULT CENTER 11
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:NORA
Authorized Official - Middle Name:
Authorized Official - Last Name:PEGUES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-843-3785
Mailing Address - Street 1:PO BOX 1681
Mailing Address - Street 2:200 GLASSCO
Mailing Address - City:CLEVELAND
Mailing Address - State:MS
Mailing Address - Zip Code:38732-1681
Mailing Address - Country:US
Mailing Address - Phone:662-843-3785
Mailing Address - Fax:662-843-3401
Practice Address - Street 1:200 GLASSCO ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:MS
Practice Address - Zip Code:38732-4434
Practice Address - Country:US
Practice Address - Phone:662-843-3785
Practice Address - Fax:662-843-3401
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ANGEL HOMEMAKER SERVICES LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-06-12
Last Update Date:2011-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care