Provider Demographics
NPI:1316658008
Name:FALLEN ANGELS LLC
Entity type:Organization
Organization Name:FALLEN ANGELS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARIAH
Authorized Official - Middle Name:RAE
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:505-389-8100
Mailing Address - Street 1:5104 SAN ADAN AVE NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87120-1834
Mailing Address - Country:US
Mailing Address - Phone:626-940-4511
Mailing Address - Fax:
Practice Address - Street 1:5104 SAN ADAN AVE NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87120-1834
Practice Address - Country:US
Practice Address - Phone:626-940-4511
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-13
Last Update Date:2022-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174H00000XOther Service ProvidersHealth EducatorGroup - Multi-Specialty