Healthcare Provider Details

I. General information

NPI: 1003402322
Provider Name (Legal Business Name): ANGELS OF GRACE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2020
Last Update Date: 12/21/2020
Certification Date: 12/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 JONES FERRY RD STE A
CARRBORO NC
27510-2036
US

IV. Provider business mailing address

104 JONES FERRY RD STE A
CARRBORO NC
27510-2036
US

V. Phone/Fax

Practice location:
  • Phone: 919-968-3724
  • Fax: 919-551-8320
Mailing address:
  • Phone: 919-968-3724
  • Fax: 919-551-8320

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: EHIMEMEN OJEABULU IBOAYA
Title or Position: DIRECTOR
Credential: MD
Phone: 336-831-6380