=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275178410
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FRIENDS OF ANGELS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/12/2019
-----------------------------------------------------
Last Update Date | 11/12/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 800 4TH AVE
-----------------------------------------------------
City | GRINNELL
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50112-2041
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 515-428-2516
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1515 N WARSON RD STE 229
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63132-1109
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-922-6147
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | KAMISHA BATES
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 314-922-6147
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------