Provider Demographics
NPI:1871963553
Name:CHEROKEE ANGEL SENIOR CARE & TRAINING CENTER
Entity type:Organization
Organization Name:CHEROKEE ANGEL SENIOR CARE & TRAINING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DOMINIQUE
Authorized Official - Middle Name:R
Authorized Official - Last Name:LOUIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-918-3066
Mailing Address - Street 1:2442 MARIETTA HWY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30114-4023
Mailing Address - Country:US
Mailing Address - Phone:404-918-3066
Mailing Address - Fax:
Practice Address - Street 1:2442 MARIETTA HWY
Practice Address - Street 2:SUITE 100
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114-4023
Practice Address - Country:US
Practice Address - Phone:404-918-3066
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-06
Last Update Date:2015-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAADC000107311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003152115AMedicaid
GA003152115CMedicaid
GA003130496AMedicaid