Healthcare Provider Details

I. General information

NPI: 1679856629
Provider Name (Legal Business Name): ANGELS CORNER LL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2011
Last Update Date: 09/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

279 HAMPTON RD S
MACON GA
31217-8536
US

IV. Provider business mailing address

279 HAMPTON RD S
MACON GA
31217-8536
US

V. Phone/Fax

Practice location:
  • Phone: 478-750-7747
  • Fax: 478-750-7747
Mailing address:
  • Phone: 478-750-7747
  • Fax: 478-750-7747

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number25896382
License Number StateGA

VIII. Authorized Official

Name: MS. JOANNE B MIMS
Title or Position: OWNER
Credential: COUNSELOR
Phone: 478-750-7747