Healthcare Provider Details

I. General information

NPI: 1932379096
Provider Name (Legal Business Name): GUARDIAN ANGEL HOMEMAKER SERVICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/05/2008
Last Update Date: 03/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1192 HIGHWAY 13 S
MORTON MS
39117-7987
US

IV. Provider business mailing address

41 S HALL RD
MORTON MS
39117-8057
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number04970592
License Number StateMS

VIII. Authorized Official

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