=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235527953
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANGELSOFMERCY FAMILY SUPOORT SERVICES,LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/05/2015
-----------------------------------------------------
Last Update Date | 01/05/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1001 ELYSIAN PL APT 323
-----------------------------------------------------
City | CHESAPEAKE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23320-2995
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-319-9909
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1001 ELYSIAN PLACE #323
-----------------------------------------------------
City | CHESAPEAKE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23320-2995
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-319-9909
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | AGENCY ADMINSTRATOR
-----------------------------------------------------
Name | MS. JUDITH MOORE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 757-319-9909
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251B00000X
-----------------------------------------------------
Taxonomy Name | Case Management Agency
-----------------------------------------------------
License Number | 04613
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------