Healthcare Provider Details

I. General information

NPI: 1578938197
Provider Name (Legal Business Name): ENCHANTED ANGELS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2015
Last Update Date: 12/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6218 ANDREA LN
WEST BLOOMFIELD MI
48322-2121
US

IV. Provider business mailing address

6218 ANDREA LN
WEST BLOOMFIELD MI
48322-2121
US

V. Phone/Fax

Practice location:
  • Phone: 313-656-8296
  • Fax:
Mailing address:
  • Phone: 313-656-8296
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number
License Number State

VIII. Authorized Official

Name: MRS. DIONE WILLIAMS
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 313-656-8296