Healthcare Provider Details

I. General information

NPI: 1497190185
Provider Name (Legal Business Name): GARDEN OF ANGELS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2013
Last Update Date: 05/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4807 N STATE ST SUITE 406
JACKSON MS
39206-4826
US

IV. Provider business mailing address

4807 N STATE ST SUITE 406
JACKSON MS
39206-4826
US

V. Phone/Fax

Practice location:
  • Phone: 601-982-3555
  • Fax: 601-982-3557
Mailing address:
  • Phone: 601-982-3555
  • Fax: 601-982-3557

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: TRICIA DUNCAN
Title or Position: BILLER
Credential:
Phone: 601-878-6945