Healthcare Provider Details

I. General information

NPI: 1972898542
Provider Name (Legal Business Name): ANGEL ADULT CENTER 11
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2011
Last Update Date: 06/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 GLASSCO ST
CLEVELAND MS
38732-4434
US

IV. Provider business mailing address

PO BOX 1681 200 GLASSCO
CLEVELAND MS
38732-1681
US

V. Phone/Fax

Practice location:
  • Phone: 662-843-3785
  • Fax: 662-843-3401
Mailing address:
  • Phone: 662-843-3785
  • Fax: 662-843-3401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. NORA PEGUES
Title or Position: ADMINISTRATOR
Credential:
Phone: 662-843-3785