MEDICARE: ANNIE'S 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	311ZA0620X	Adult Care Home Facility

General Provider Information

NPI Number	:	1861330714
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ANNIE'S ANGELS LLC

Provider Business Mailing Address
First Line	:	2140 CONCORD ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48207-3652
Country	:	US
Telephone Number	:	313-477-5926
Fax Number	:

Provider Business Practice Location Address
First Line	:	2140 CONCORD ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48207-3652
Country	:	US
Telephone Number	:	313-477-5926
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. WANDA L JOHNSON
Credential	:	JOHNSON
Telephone Number	:	313-477-5926

Provider Enumeration Date	:	03/23/2026
Last Update Date	:	03/23/2026

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Directions to “ANNIE'S ANGELS LLC ” Practice Location

Language	Start Address	Practice Location

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