Angel's Home Icf, Inc.

Primary specialty

Nursing Facility/Intermediate Care FacilityTaxonomy code 313M00000X

Legal business name

ANGEL'S HOME ICF, INC.

Practice address

10712 Waterbury Dr
Stockton, CA 95209-4212

Phone

(510) 289-3848

Fax

(209) 477-1449

NPI assigned

Dec 23, 2014

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Mr. Larry R Angel, PA-C

Title

President / Administrator

Phone

(510) 289-3848

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Intermediate care facility for individuals with intellectual disabilities certification: CCN 55G743

Legal name

ANGEL'S HOME ICF, INC

Certification status

Active

Provider type (POS)

Intermediate care facility for individuals with intellectual disabilities

Participating since

Sep 26, 2016

Last certification

May 29, 2025

Beds

6

Ownership / control type

Private (proprietary)

Facility address

10712 Waterbury Drive
Stockton, CA 95209

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1419292800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1419292800000",
    "number": "1205224334",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "10712 WATERBURY DR",
            "city": "STOCKTON",
            "state": "CA",
            "postal_code": "952094212",
            "telephone_number": "510-289-3848",
            "fax_number": "209-477-1449"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "10712 WATERBURY DR",
            "city": "STOCKTON",
            "state": "CA",
            "postal_code": "952094212",
            "telephone_number": "510-289-3848",
            "fax_number": "209-477-1449"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "ANGEL'S HOME ICF, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2014-12-23",
        "last_updated": "2014-12-23",
        "status": "A",
        "authorized_official_last_name": "ANGEL",
        "authorized_official_first_name": "LARRY",
        "authorized_official_middle_name": "R",
        "authorized_official_title_or_position": "PRESIDENT / ADMINISTRATOR",
        "authorized_official_telephone_number": "510-289-3848",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_credential": "PA-C"
    },
    "taxonomies": [
        {
            "code": "313M00000X",
            "taxonomy_group": "",
            "desc": "Nursing Facility/Intermediate Care Facility",
            "state": "CA",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Mark Ryan Andriese
• Lashontiana Trevaughn Andy
• Anesthesiology Consultants Medical Group, Inc.
• Kangho Ang
• Lourdes De Guzman Angel
• Christian S Angeles
• Lizbeth Melissa Angeles
• Raymond John Angeli, D.D.S.
• Jarenny Anguiano Arreola
• Amanda Elizabeth Anguiano

• Nursing Facility/Intermediate Care Facility in Stockton, CA
• Providers in Stockton, CA by specialty
• Nursing Facility/Intermediate Care Facility in California

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 23, 2014; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; facility enrollments, owners and changes of ownership; Provider of Services certification data.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.