1346396793 NPI number — GUARDIAN ANGEL HEALTHCARE, LLC

Table of content: (NPI 1346396793)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346396793 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:
1346396793
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
107 CURRIN LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WARRENTON
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27589-2249
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
252-257-9349
Provider Business Mailing Address Fax Number:
252-492-9088

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
314 S GARNETT ST
Provider Second Line Business Practice Location Address:
SUITE 202
Provider Business Practice Location Address City Name:
HENDERSON
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27536-4538
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
252-492-9205
Provider Business Practice Location Address Fax Number:
252-492-9088
Provider Enumeration Date:
01/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WILLIAMS
Authorized Official First Name:
CORNELIUS
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT - REGISTERED AGENT
Authorized Official Telephone Number:
252-257-9349

Provider Taxonomy Codes

  • Taxonomy code: 320600000X , with the licence number:  MHL091077 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 7805648 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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