1467998021 NPI number — GUARDIAN HEALTH CARE SERVICES

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 1467998021 NPI number — GUARDIAN HEALTH CARE SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GUARDIAN HEALTH CARE SERVICES
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:
D'AMORE HEALTHCARE
Provider Other Organization Name Type Code:
3
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:
1467998021
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/09/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3044 GRANT AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COSTA MESA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92626-2855
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
949-402-9520
Provider Business Mailing Address Fax Number:
714-242-9700

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3044 GRANT AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COSTA MESA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92626-2855
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
949-402-9520
Provider Business Practice Location Address Fax Number:
714-242-9700
Provider Enumeration Date:
01/06/2017

Additional Information

Authorized Official

Authorized Official Last Name:
SMITH
Authorized Official First Name:
BENJAMIN
Authorized Official Middle Name:
WOODFORD
Authorized Official Title or Position:
CHIEF ADMINISTRATIVE OFFICER
Authorized Official Telephone Number:
949-892-3020

Provider Taxonomy Codes

  • Taxonomy code: 323P00000X , with the licence number:  MHBS160214 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 306005248 . This is a "CALIFORNIA DEPARTMENT OF SOCIAL SERVICES" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: MHBS160214 . This is a "CALIFORNIA DEPARTMENT OF HEALTH CARE SERVICES" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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