Healthcare Provider Details

I. General information

NPI: 1134264542
Provider Name (Legal Business Name): GUARDIAN ANGEL HEALTHCARE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6434 DALE DR
MARION MS
39342-8704
US

IV. Provider business mailing address

41 S HALL RD
MORTON MS
39117-8057
US

V. Phone/Fax

Practice location:
  • Phone: 601-482-5606
  • Fax: 601-482-7801
Mailing address:
  • Phone: 601-732-8473
  • Fax: 601-732-8037

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number1196
License Number StateMS

VIII. Authorized Official

Name: DR. PAULETTE H BUTLER
Title or Position: CEO
Credential: PHD
Phone: 601-732-8473