Provider Demographics
NPI:1265739163
Name:ANGEL HOME HEALTH AGENCY SERVICE, CORP.
Entity type:Organization
Organization Name:ANGEL HOME HEALTH AGENCY SERVICE, CORP.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MARTHA
Authorized Official - Middle Name:NGOZI
Authorized Official - Last Name:EGIEBOR
Authorized Official - Suffix:
Authorized Official - Credentials:REGISTERED NURSE
Authorized Official - Phone:708-410-2007
Mailing Address - Street 1:10001 W ROOSEVELT RD STE 308
Mailing Address - Street 2:
Mailing Address - City:WESTCHESTER
Mailing Address - State:IL
Mailing Address - Zip Code:60154-2662
Mailing Address - Country:US
Mailing Address - Phone:708-410-2007
Mailing Address - Fax:708-410-2017
Practice Address - Street 1:10001 W ROOSEVELT RD STE 308
Practice Address - Street 2:
Practice Address - City:WESTCHESTER
Practice Address - State:IL
Practice Address - Zip Code:60154-2662
Practice Address - Country:US
Practice Address - Phone:708-410-2007
Practice Address - Fax:708-410-2017
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-12
Last Update Date:2022-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1011319251E00000X
251J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care
No251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1011319OtherDEPARTMENT OF PUBLIC HEALTH