1174082036 NPI number — GUARDIAN ANGEL HEALTHCARE, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174082036 NPI number — GUARDIAN ANGEL HEALTHCARE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GUARDIAN ANGEL HEALTHCARE, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174082036
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/19/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2002
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HENDERSON
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27536-2002
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
252-204-1381
Provider Business Mailing Address Fax Number:
252-598-1021

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1556 NC HWY 56
Provider Second Line Business Practice Location Address:
B-104
Provider Business Practice Location Address City Name:
CREEDMOOR
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27422
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
252-252-1381
Provider Business Practice Location Address Fax Number:
252-598-0051
Provider Enumeration Date:
03/19/2019

Additional Information

Authorized Official

Authorized Official Last Name:
WILLIAMS
Authorized Official First Name:
CORNELIUS
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT / CEO
Authorized Official Telephone Number:
252-204-1381

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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