Healthcare Provider Details

I. General information

NPI: 1205106770
Provider Name (Legal Business Name): ANGEL PRESTIGE RESIDENTIAL CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/30/2011
Last Update Date: 01/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3305 MARCEL COURT
SAN JOSE CA
95135
US

IV. Provider business mailing address

3305 MARCEL COURT
SAN JOSE CA
95135
US

V. Phone/Fax

Practice location:
  • Phone: 408-440-0920
  • Fax:
Mailing address:
  • Phone: 408-440-0920
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License NumberRN41086
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number4185AGC-6
License Number StateNV
# 3
Primary TaxonomyN
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number3220AGC-13
License Number StateNV

VIII. Authorized Official

Name: HERMANDO ESGUERRA
Title or Position: ADMINISTRATOR
Credential:
Phone: 408-568-0615