Healthcare Provider Details

I. General information

NPI: 1841504511
Provider Name (Legal Business Name): MELINDAS GUARDIAN ANGEL PERSONAL CARE HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2010
Last Update Date: 08/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

593 EIGHTH ST
STATHAM GA
30666-1830
US

IV. Provider business mailing address

1301 DIANNE WAY
WINDER GA
30680-5621
US

V. Phone/Fax

Practice location:
  • Phone: 770-725-7407
  • Fax: 678-963-2761
Mailing address:
  • Phone: 678-558-2116
  • Fax: 678-963-2761

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number007010311
License Number StateGA

VIII. Authorized Official

Name: MS. KAREN MECHELLE DELANEY
Title or Position: ADMINISTRATOR
Credential:
Phone: 678-558-2116