Healthcare Provider Details

I. General information

NPI: 1780211284
Provider Name (Legal Business Name): ANGEL HEART HOSPICE AND PALLIATIVE CARE MOBILE LAB
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/25/2020
Last Update Date: 03/02/2022
Certification Date: 03/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2302 PARKLAKE DR NE # 568
ATLANTA GA
30345-2896
US

IV. Provider business mailing address

2302 PARKLAKE DR NE STE 568
ATLANTA GA
30345-2896
US

V. Phone/Fax

Practice location:
  • Phone: 470-381-2983
  • Fax:
Mailing address:
  • Phone: 470-381-2139
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code247ZC0005X
TaxonomyClinical Laboratory Director (Non-physician)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code251G00000X
TaxonomyCommunity Based Hospice Care Agency
License Number
License Number State

VIII. Authorized Official

Name: DWELVER NIKKI WEBB
Title or Position: CEO
Credential:
Phone: 470-381-2983