=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396322640
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANGEL HEART HOSPICE AND PALLIATIVE CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/24/2021
-----------------------------------------------------
Last Update Date | 03/24/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2302 PARKLAKE DR NE
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30345-2896
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 470-381-2983
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2302 PARKLAKE DR NE STE 568
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30345-2896
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-281-5106
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | DWELVER NIKKI WEBB
-----------------------------------------------------
Credential | CHAPLAIN
-----------------------------------------------------
Telephone | 470-381-2983
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251G00000X
-----------------------------------------------------
Taxonomy Name | Community Based Hospice Care Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------