Healthcare Provider Details

I. General information

NPI: 1952830143
Provider Name (Legal Business Name): MARTHA GUARDADO 311ZA0620X
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2017
Last Update Date: 06/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5689 GENTIAN CT SE
KENTWOOD MI
49508-6403
US

IV. Provider business mailing address

5689 GENTIAN CT SE
KENTWOOD MI
49508-6403
US

V. Phone/Fax

Practice location:
  • Phone: 616-325-0222
  • Fax:
Mailing address:
  • Phone: 616-325-0222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License NumberAF410381126
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: