Healthcare Provider Details

I. General information

NPI: 1609197896
Provider Name (Legal Business Name): GUARDIAN ANGEL HEALTHCARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2010
Last Update Date: 09/25/2021
Certification Date: 09/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

270 CHARLES ST
HENDERSON NC
27536-4328
US

IV. Provider business mailing address

270 CHARLES ST
HENDERSON NC
27536-4328
US

V. Phone/Fax

Practice location:
  • Phone: 252-572-4487
  • Fax: 252-572-2147
Mailing address:
  • Phone: 252-572-4487
  • Fax: 252-572-2147

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License NumberMHL-091-087
License Number StateNC

VIII. Authorized Official

Name: MR. CORNELIUS WILLIAMS
Title or Position: PRESIDENT/REGISTERED AGENT
Credential:
Phone: 252-204-1381