Provider Demographics
NPI:1386088193
Name:GARDEN OF ANGELS LLC
Entity type:Organization
Organization Name:GARDEN OF ANGELS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/ CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:PAMALA
Authorized Official - Middle Name:THOMPSON
Authorized Official - Last Name:JEFFERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-982-3555
Mailing Address - Street 1:4807 N STATE ST STE 406
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39206-4826
Mailing Address - Country:US
Mailing Address - Phone:601-982-3555
Mailing Address - Fax:601-982-3557
Practice Address - Street 1:4807 N STATE ST STE 406
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39206-4826
Practice Address - Country:US
Practice Address - Phone:601-982-3555
Practice Address - Fax:601-982-3557
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS1215270921Medicaid
MS1447593082Medicaid
MS1801139449Medicaid
MS1265775803Medicaid
MS1114260882Medicaid
MS1548503170Medicaid
MS1578806246Medicaid
MS1265775894Medicaid