Provider Demographics
NPI:1215159819
Name:ANGEL WINGS CENTER OF HEALING
Entity type:Organization
Organization Name:ANGEL WINGS CENTER OF HEALING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:BOBETTE
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:PAGE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:208-552-6900
Mailing Address - Street 1:808 PANCHERI DR
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83402-3344
Mailing Address - Country:US
Mailing Address - Phone:208-552-6900
Mailing Address - Fax:208-552-4973
Practice Address - Street 1:808 PANCHERI DR.
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402
Practice Address - Country:US
Practice Address - Phone:208-757-0330
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-273731041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID2257711OtherCIGNA BEHAVIORAL HEALTH
ID=========OtherIDAHO PHYSICIANS NETWORK