Healthcare Provider Details

I. General information

NPI: 1346015427
Provider Name (Legal Business Name): ANGELIC ADVANCE SUPPORT COORDINATOR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/20/2023
Last Update Date: 12/03/2023
Certification Date: 12/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

399 2ND ST APT 3R
JERSEY CITY NJ
07302-2248
US

IV. Provider business mailing address

1107 CAMERON RD
EFFORT PA
18330-2301
US

V. Phone/Fax

Practice location:
  • Phone: 319-300-0095
  • Fax:
Mailing address:
  • Phone: 319-464-1188
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code251X00000X
TaxonomySupports Brokerage Agency
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number
License Number State

VIII. Authorized Official

Name: NEEMA JOHN MUSHI
Title or Position: CEO
Credential:
Phone: 319-300-0095