=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235843384
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANGELIC CARE LIVING LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/12/2023
-----------------------------------------------------
Last Update Date | 06/14/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 207 BOGDEN BLVD STE H
-----------------------------------------------------
City | MILLVILLE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08332-4844
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-329-9619
-----------------------------------------------------
Fax | 856-329-9908
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 207 BOGDEN BLVD
-----------------------------------------------------
City | MILLVILLE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08332-4844
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-329-9619
-----------------------------------------------------
Fax | 856-329-9908
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE OFFICER
-----------------------------------------------------
Name | MRS. CORLENE ANN ROXANNE LONDON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 856-329-9619
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 253Z00000X
-----------------------------------------------------
Taxonomy Name | In Home Supportive Care Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------