Provider Demographics
NPI:1336408632
Name:LITTLE ANGELS
Entity Type:Organization
Organization Name:LITTLE ANGELS
Other - Org Name:N/A
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:RENEA
Authorized Official - Last Name:CRUZ
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:208-313-0711
Mailing Address - Street 1:1680 WOODRUFF PARK
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-3330
Mailing Address - Country:US
Mailing Address - Phone:208-313-0711
Mailing Address - Fax:
Practice Address - Street 1:1680 WOODRUFF PARK
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401-3330
Practice Address - Country:US
Practice Address - Phone:208-313-0711
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-08
Last Update Date:2013-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-91882084P0800X
2084P0804X
IDPA-334363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty