Healthcare Provider Details

I. General information

NPI: 1023352846
Provider Name (Legal Business Name): GUARDIAN ANGEL ADULT DAY SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2012
Last Update Date: 07/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1028 RUSSWIN ST
CLARKSDALE MS
38614-4610
US

IV. Provider business mailing address

PO BOX 1052
CLARKSDALE MS
38614-1052
US

V. Phone/Fax

Practice location:
  • Phone: 662-902-2921
  • Fax:
Mailing address:
  • Phone: 662-902-2921
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: TINEKA BAILEY
Title or Position: OWNER
Credential:
Phone: 662-902-2921