MEDICARE: ANGELIC ADVANCE SUPPORT COORDINATOR

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	305S00000X	Point of Service
2	251B00000X	Case Management Agency
3	251C00000X	Developmentally Disabled Services Day Training Agency
4	251K00000X	Public Health or Welfare Agency
5	251S00000X	Community/Behavioral Health Agency
6	261QA0600X	Adult Day Care Clinic/Center
7	251X00000X	Supports Brokerage Agency

General Provider Information

NPI Number	:	1346015427
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ANGELIC ADVANCE SUPPORT COORDINATOR

Provider Business Mailing Address
First Line	:	1107 CAMERON RD
Second Line	:
City	:	EFFORT
State	:	PA
Zip	:	18330-2301
Country	:	US
Telephone Number	:	319-464-1188
Fax Number	:

Provider Business Practice Location Address
First Line	:	399 2ND ST APT 3R
Second Line	:
City	:	JERSEY CITY
State	:	NJ
Zip	:	07302-2248
Country	:	US
Telephone Number	:	319-300-0095
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	NEEMA JOHN MUSHI
Credential	:
Telephone Number	:	319-300-0095

Provider Enumeration Date	:	11/20/2023
Last Update Date	:	12/03/2023

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