Healthcare Provider Details

I. General information

NPI: 1053456459
Provider Name (Legal Business Name): GUARDIAN ANGEL HOSPICE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2007
Last Update Date: 12/28/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41 S HALL RD
MORTON MS
39117-8057
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 Code315D00000X
TaxonomyInpatient Hospice
License Number059
License Number StateMS

VIII. Authorized Official

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