Provider Demographics
NPI:1669962346
Name:MARY'S ANGEL'S HOME CARE AGENCY LLC
Entity type:Organization
Organization Name:MARY'S ANGEL'S HOME CARE AGENCY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:LAQWANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:DENNIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-674-5075
Mailing Address - Street 1:PO BOX 350264
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32235-0264
Mailing Address - Country:US
Mailing Address - Phone:904-674-5075
Mailing Address - Fax:
Practice Address - Street 1:5350 ARLINGTON EXPY APT 4011
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32211-6865
Practice Address - Country:US
Practice Address - Phone:904-674-5075
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-17
Last Update Date:2018-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care