Healthcare Provider Details

I. General information

NPI: 1497823181
Provider Name (Legal Business Name): ANGEL ARMS LLC ELAINE NIEHAUS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1228 10TH AVE N
SAINT CLOUD MN
56303-2707
US

IV. Provider business mailing address

829 7TH AVE N
SAINT CLOUD MN
56303-2905
US

V. Phone/Fax

Practice location:
  • Phone: 320-230-0764
  • Fax:
Mailing address:
  • Phone: 320-230-2472
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number17044193
License Number StateMN

VIII. Authorized Official

Name: REBECCA ANN CAMPAANELLA
Title or Position: ADMINISTRATOR
Credential:
Phone: 218-628-1684