=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356940761
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANGEL LIVING, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/19/2020
-----------------------------------------------------
Last Update Date | 10/19/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3978 OLD WASHINGTON RD
-----------------------------------------------------
City | WALDORF
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20602-3217
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-374-9410
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8919 HICKORY HILL AVE
-----------------------------------------------------
City | LANHAM
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20706-2851
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-577-2999
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | IDRIS UGHIOVHE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 202-210-8900
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------