Provider Demographics
NPI:1891448064
Name:ANGELIC HEALTH PRACTICE GROUP
Entity type:Organization
Organization Name:ANGELIC HEALTH PRACTICE GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MIKUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:609-822-7979
Mailing Address - Street 1:8025 BLACK HORSE PIKE STE 501
Mailing Address - Street 2:
Mailing Address - City:PLEASANTVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08232-2967
Mailing Address - Country:US
Mailing Address - Phone:609-822-7979
Mailing Address - Fax:
Practice Address - Street 1:923C MEDICAL CIRCLE
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29572
Practice Address - Country:US
Practice Address - Phone:843-356-9078
Practice Address - Fax:843-356-4086
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-28
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LC1500XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCommunity HealthGroup - Single Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty