MEDICARE: ANGEL ADULT CENTER 11

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QA0600X	Adult Day Care Clinic/Center

General Provider Information

NPI Number	:	1972898542
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ANGEL ADULT CENTER 11

Provider Business Mailing Address
First Line	:	PO BOX 1681
Second Line	:	200 GLASSCO
City	:	CLEVELAND
State	:	MS
Zip	:	38732-1681
Country	:	US
Telephone Number	:	662-843-3785
Fax Number	:	662-843-3401

Provider Business Practice Location Address
First Line	:	200 GLASSCO ST
Second Line	:
City	:	CLEVELAND
State	:	MS
Zip	:	38732-4434
Country	:	US
Telephone Number	:	662-843-3785
Fax Number	:	662-843-3401

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MS. NORA PEGUES
Credential	:
Telephone Number	:	662-843-3785

Provider Enumeration Date	:	06/12/2011
Last Update Date	:	06/12/2011

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Directions to “ANGEL ADULT CENTER 11 ” Practice Location

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