Healthcare Provider Details

I. General information

NPI: 1730344425
Provider Name (Legal Business Name): QUEEN OF ANGELS QUALITY CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2008
Last Update Date: 07/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 W ROUTE 66 SUITE 206
GLENDORA CA
91740-4105
US

IV. Provider business mailing address

620 W ROUTE 66 SUITE 206
GLENDORA CA
91740-4105
US

V. Phone/Fax

Practice location:
  • Phone: 626-963-5900
  • Fax: 626-963-5900
Mailing address:
  • Phone: 626-963-5900
  • Fax: 626-963-5900

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number StateCA

VIII. Authorized Official

Name: JIMMY JOLO GONZALES
Title or Position: ADMINISTRATOR
Credential:
Phone: 626-963-5900