Provider Demographics
NPI:1053714972
Name:ACTIVE ANGEL CAREGIVER AGENCY
Entity type:Organization
Organization Name:ACTIVE ANGEL CAREGIVER AGENCY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:PARMODH
Authorized Official - Middle Name:PARDEEP
Authorized Official - Last Name:DUTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-725-9073
Mailing Address - Street 1:13605 HEATHER WAY
Mailing Address - Street 2:
Mailing Address - City:HAWTHORNE
Mailing Address - State:CA
Mailing Address - Zip Code:90250-6474
Mailing Address - Country:US
Mailing Address - Phone:310-725-9073
Mailing Address - Fax:
Practice Address - Street 1:13605 HEATHER WAY
Practice Address - Street 2:
Practice Address - City:HAWTHORNE
Practice Address - State:CA
Practice Address - Zip Code:90250-6474
Practice Address - Country:US
Practice Address - Phone:310-725-9073
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-06
Last Update Date:2014-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA464040257315D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315D00000XNursing & Custodial Care FacilitiesHospice, Inpatient