MEDICARE: HEAVENLY ANGEL HOSPICE INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251G00000X	Community Based Hospice Care Agency

General Provider Information

NPI Number	:	1144816307
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HEAVENLY ANGEL HOSPICE INC

Provider Business Mailing Address
First Line	:	202 E AIRPORT DR STE 158
Second Line	:
City	:	SAN BERNARDINO
State	:	CA
Zip	:	92408-3428
Country	:	US
Telephone Number	:	909-571-5949
Fax Number	:

Provider Business Practice Location Address
First Line	:	202 E AIRPORT DR STE 158
Second Line	:
City	:	SAN BERNARDINO
State	:	CA
Zip	:	92408-3428
Country	:	US
Telephone Number	:	909-571-5949
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MANE SHAMIRYAN
Credential	:
Telephone Number	:	909-571-5949

Provider Enumeration Date	:	12/11/2020
Last Update Date	:	12/11/2020

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