Provider Demographics
NPI:1538691704
Name:ANGEL WINGS HOME CARE
Entity type:Organization
Organization Name:ANGEL WINGS HOME CARE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATIONS OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:TAYLOR
Authorized Official - Last Name:MCKINNIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:434-836-8711
Mailing Address - Street 1:2276 FRANKLIN TPKE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:DANVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24540-5284
Mailing Address - Country:US
Mailing Address - Phone:434-836-8711
Mailing Address - Fax:
Practice Address - Street 1:2276 FRANKLIN TPKE
Practice Address - Street 2:SUITE 104
Practice Address - City:DANVILLE
Practice Address - State:VA
Practice Address - Zip Code:24540-5284
Practice Address - Country:US
Practice Address - Phone:434-836-8711
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-28
Last Update Date:2017-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAHCO-17408251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0104115214Medicaid
VA0104148819Medicaid