MEDICARE: CHARLIES ANGELS HEALTHCARE 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	251B00000X	Case Management Agency
2	253Z00000X	In Home Supportive Care Agency

General Provider Information

NPI Number	:	1598435695
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHARLIES ANGELS HEALTHCARE LLC

Provider Business Mailing Address
First Line	:	412 BEACH 38TH ST
Second Line	:
City	:	FAR ROCKAWAY
State	:	NY
Zip	:	11691-1514
Country	:	US
Telephone Number	:	718-598-3077
Fax Number	:	855-589-3052

Provider Business Practice Location Address
First Line	:	412 BEACH 38TH ST
Second Line	:
City	:	FAR ROCKAWAY
State	:	NY
Zip	:	11691-1514
Country	:	US
Telephone Number	:	610-619-6069
Fax Number	:

Authorized Official
Title or Position	:	OWNER/CEO
Name	:	EBONY BUSSEY
Credential	:
Telephone Number	:	718-598-3077

Provider Enumeration Date	:	09/20/2021
Last Update Date	:	07/24/2025

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