=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528738317
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHARMING ANGELS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/14/2021
-----------------------------------------------------
Last Update Date | 09/14/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 21703 PROSPECT HL
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78258-2508
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-724-5568
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 21703 PROSPECT HL
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78258-2508
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-724-5568
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | CHARMAINE ANNA-LISA MIXON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 210-724-5568
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 164X00000X
-----------------------------------------------------
Taxonomy Name | Licensed Vocational Nurse
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------