MEDICARE: ANGELS OF GRACE COMMUNITY WELLNESS CENTER, 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	261Q00000X	Clinic/Center

General Provider Information

NPI Number	:	1154810844
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ANGELS OF GRACE COMMUNITY WELLNESS CENTER, INC.

Provider Business Mailing Address
First Line	:	PO BOX 1510
Second Line	:
City	:	CAIRO
State	:	GA
Zip	:	39828-0970
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	195 MARTIN LUTHER KING JR AVE SW
Second Line	:
City	:	CAIRO
State	:	GA
Zip	:	39828-2605
Country	:	US
Telephone Number	:	229-397-9355
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	DR. MARY WEAVER-ANDERSON
Credential	:	DRPH
Telephone Number	:	229-397-9355

Provider Enumeration Date	:	05/08/2018
Last Update Date	:	06/13/2020

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