Healthcare Provider Details

I. General information

NPI: 1669385100
Provider Name (Legal Business Name): ELITE CROWNING GLORY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2026
Last Update Date: 09/25/2026
Certification Date: 09/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

413 N 5TH ST
JESUP GA
31545-1024
US

IV. Provider business mailing address

1425 E OGLETHORPE HWY # 1002
HINESVILLE GA
31313-1219
US

V. Phone/Fax

Practice location:
  • Phone: 912-630-7678
  • Fax:
Mailing address:
  • Phone: 912-630-7678
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name: MRS. ANGELA DARDEN-RIVERS
Title or Position: CEO/OWNER
Credential:
Phone: 912-630-7678