Healthcare Provider Details

I. General information

NPI: 1154063345
Provider Name (Legal Business Name): MINK ANGEL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/08/2022
Last Update Date: 04/25/2022
Certification Date: 04/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5631 N 16TH ST
PHILADELPHIA PA
19141-1710
US

IV. Provider business mailing address

171 W SEYMOUR ST
PHILADELPHIA PA
19144-3661
US

V. Phone/Fax

Practice location:
  • Phone: 267-627-4740
  • Fax:
Mailing address:
  • Phone: 126-740-8798
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number
License Number State

VIII. Authorized Official

Name: ANGELA RACHELLE JOHNSON
Title or Position: CEO
Credential:
Phone: 267-408-7984