MEDICARE: AMAZING ANGELS 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	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility

General Provider Information

NPI Number	:	1679225064
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AMAZING ANGELS LLC

Provider Business Mailing Address
First Line	:	PO BOX 274
Second Line	:
City	:	PARKER
State	:	CO
Zip	:	80134-0274
Country	:	US
Telephone Number	:	720-635-4734
Fax Number	:	720-420-1322

Provider Business Practice Location Address
First Line	:	4810 JET WING CIR W
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80916-2149
Country	:	US
Telephone Number	:	720-635-4734
Fax Number	:	720-420-1322

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MELANY WONG
Credential	:
Telephone Number	:	720-635-4734

Provider Enumeration Date	:	01/26/2022
Last Update Date	:	01/26/2022

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Directions to “AMAZING ANGELS LLC ” Practice Location

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