MEDICARE: ANGEL HOUSE LLC

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	251E00000X	Home Health Agency

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	104700047	OTHER	CA	HOME CARE ORGANIZATION LICENSE

General Provider Information

NPI Number	:	1326707043
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ANGEL HOUSE LLC

Provider Business Mailing Address
First Line	:	1265 W SHAW AVE STE 100
Second Line	:
City	:	FRESNO
State	:	CA
Zip	:	93711-3717
Country	:	US
Telephone Number	:	183-376-2643
Fax Number	:

Provider Business Practice Location Address
First Line	:	1265 W SHAW AVE STE 100
Second Line	:
City	:	FRESNO
State	:	CA
Zip	:	93711-3717
Country	:	US
Telephone Number	:	183-376-2643
Fax Number	:

Authorized Official
Title or Position	:	VICE PRESIDENT/DIRECTING MANAGER
Name	:	ALEXIS HORNSBY
Credential	:
Telephone Number	:	833-762-6435

Provider Enumeration Date	:	12/09/2021
Last Update Date	:	12/09/2021

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Directions to “ANGEL HOUSE LLC ” Practice Location

Language	Start Address	Practice Location

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