=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457864076
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANGEL WATCH HOME CARE, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/06/2017
-----------------------------------------------------
Last Update Date | 04/15/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1869 S 8TH ST STE B
-----------------------------------------------------
City | FERNANDINA BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32034-3072
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-491-3222
-----------------------------------------------------
Fax | 904-775-5982
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3854 AMERICAN WAY STE A
-----------------------------------------------------
City | BATON ROUGE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70816-4897
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 225-292-2031
-----------------------------------------------------
Fax | 225-295-9678
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. PAUL KUSSEROW
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 225-292-2031
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------