Healthcare Provider Details

I. General information

NPI: 1083917934
Provider Name (Legal Business Name): ANGELS UNIQUE LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2010
Last Update Date: 12/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13520 17TH ST
DADE CITY FL
33525-5211
US

IV. Provider business mailing address

13520 17TH ST
DADE CITY FL
33525-5211
US

V. Phone/Fax

Practice location:
  • Phone: 352-523-1111
  • Fax: 352-523-1122
Mailing address:
  • Phone: 352-523-1111
  • Fax: 352-523-1122

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number230477
License Number StateFL

VIII. Authorized Official

Name: TERRY W PERGERSON
Title or Position: DIRECTOR
Credential:
Phone: 352-523-1111