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General NPI Number Information
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NPI Number | 1467812941
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Entity Type | Organization
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Legal Business Name | ANGEL'S INN
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Dates
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Enumeration Date | 02/26/2016
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Last Update Date | 02/26/2016
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Provider Practice Location Address
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Address Line | 518 PINE ST
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City | WATERTOWN
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State | NY
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Zip | 13601-3235
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Country | US
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Telephone | 315-782-2238
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Fax |
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Provider Business Mailing Address
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Address Line | 518 PINE ST
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City | WATERTOWN
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State | NY
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Zip | 13601-3235
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Country | US
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Telephone | 315-782-2238
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Fax |
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | MR. FLOYD AUSTIN BRADLEY
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Credential | LHNA
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Telephone | 315-782-2238
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 376G00000X
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Taxonomy Name | Nursing Home Administrator
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License Number | 05684
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License Number State | NY
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Taxonomy #2
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Taxonomy Code | 311ZA0620X
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Taxonomy Name | Adult Care Home Facility
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License Number | 330F036
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License Number State | NY
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