Healthcare Provider Details

I. General information

NPI: 1104475763
Provider Name (Legal Business Name): ANGEL FAMILY CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/06/2019
Last Update Date: 06/21/2021
Certification Date: 06/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28370 N GOLD LN
SAN TAN VALLEY AZ
85143-6059
US

IV. Provider business mailing address

28370 N GOLD LN
SAN TAN VALLEY AZ
85143-6059
US

V. Phone/Fax

Practice location:
  • Phone: 480-720-3393
  • Fax:
Mailing address:
  • Phone: 480-720-3393
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: MS. CHANTELLE EZINNE OGUADIMMA
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: LAC
Phone: 480-720-3393