Provider Demographics
NPI:1962801175
Name:SENIOR ANGELS INC
Entity type:Organization
Organization Name:SENIOR ANGELS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LAKEYA
Authorized Official - Middle Name:TRAMAINE
Authorized Official - Last Name:STOCKTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-989-6527
Mailing Address - Street 1:9368 FORRER ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48228-2116
Mailing Address - Country:US
Mailing Address - Phone:313-989-6527
Mailing Address - Fax:
Practice Address - Street 1:9368 FORRER ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48228-2116
Practice Address - Country:US
Practice Address - Phone:313-989-6527
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-14
Last Update Date:2014-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization