Provider Demographics
NPI:1427649433
Name:ANGEL VINE AFH LLC
Entity type:Organization
Organization Name:ANGEL VINE AFH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:RUSSELL
Authorized Official - Last Name:WACHTER
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:360-880-1751
Mailing Address - Street 1:199 SCHOOLHOUSE RD
Mailing Address - Street 2:
Mailing Address - City:WINLOCK
Mailing Address - State:WA
Mailing Address - Zip Code:98596-9718
Mailing Address - Country:US
Mailing Address - Phone:360-880-1751
Mailing Address - Fax:360-242-0125
Practice Address - Street 1:275 W VINE ST
Practice Address - Street 2:
Practice Address - City:NAPAVINE
Practice Address - State:WA
Practice Address - Zip Code:98532-7641
Practice Address - Country:US
Practice Address - Phone:360-262-3406
Practice Address - Fax:360-242-0125
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-02
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home