1154063345 NPI number — MINK ANGEL LLC

Table of content: (NPI 1154063345)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154063345 NPI number — MINK ANGEL LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MINK ANGEL LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1154063345
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/25/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
171 W SEYMOUR ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHILADELPHIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19144-3661
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
126-740-8798
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5631 N 16TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19141-1710
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
267-627-4740
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/08/2022

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
JOHNSON
Authorized Official First Name:
ANGELA
Authorized Official Middle Name:
RACHELLE
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
267-408-7984

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1744P3200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)