# HEAVENLY ANGELS GROUP HOME, INC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1457591356
- **Authorized official:** MS. ANTOINETTA DEMTRIA FULTON (ONWER/ DIRECTOR)
- **Authorized official phone:** (336) 230-0808

## Contact information

- **Practice address:** 3725 ANITA LN, GREENSBORO, NC 27405-9412
- **Practice address phone:** (336) 358-2137
- **Practice address fax:** (336) 358-2136
- **Mailing address:** 503 W MCGEE ST, GREENSBORO, NC 27401-2702
- **Mailing address phone:** (336) 230-0808
- **Mailing address fax:** (336) 230-0842

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 320600000X | Intellectual and/or Developmental Disabilities Residential Treatment Facility | MHL-041-895 | NC | Yes |

## Other

- **Enumeration date:** 03/05/2009
- **Last updated:** 03/05/2009