=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568869303
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANGEL CONGREGATE LIVING, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/21/2014
-----------------------------------------------------
Last Update Date | 09/15/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 38536 DESERT VIEW DR
-----------------------------------------------------
City | PALMDALE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93551
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 661-418-5830
-----------------------------------------------------
Fax | 661-418-5831
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 38536 DESERT VIEW DR
-----------------------------------------------------
City | PALMDALE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93551-4301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 661-418-5830
-----------------------------------------------------
Fax | 661-418-5831
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | HRANT DANAKIAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 661-418-5830
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------