=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417739780
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANGIE'S HOUSE OF LOVE & PATIENCE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/19/2023
-----------------------------------------------------
Last Update Date | 10/19/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2411 S NC HIGHWAY 11
-----------------------------------------------------
City | ROSE HILL
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28458-8467
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-289-7678
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2411 S NC HIGHWAY 11
-----------------------------------------------------
City | ROSE HILL
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28458-8467
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-289-7678
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | ANGELA WASHINGTON MOORE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 910-289-7678
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 311ZA0620X
-----------------------------------------------------
Taxonomy Name | Adult Care Home Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------