Provider Demographics
NPI:1184250631
Name:ANGEL CARE HOME CARE LLC
Entity type:Organization
Organization Name:ANGEL CARE HOME CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SHONDRA
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:MHA-GER, BSN,RN
Authorized Official - Phone:912-483-3800
Mailing Address - Street 1:2005 VETERANS BLVD STE A13
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:GA
Mailing Address - Zip Code:31021-7504
Mailing Address - Country:US
Mailing Address - Phone:478-353-1080
Mailing Address - Fax:478-353-1260
Practice Address - Street 1:2005 VETERANS BLVD STE A13
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:GA
Practice Address - Zip Code:31021-7504
Practice Address - Country:US
Practice Address - Phone:478-353-1080
Practice Address - Fax:478-353-1260
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-17
Last Update Date:2023-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003231057BMedicaid
GA025-R-2032OtherGEORGIA DCH PRIVATE HOME CARE PROVIDER PERMIT NUMBER
GA003231057AMedicaid