Healthcare Provider Details

I. General information

NPI: 1720136963
Provider Name (Legal Business Name): GUARDIAN ANGEL HEALTHCARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/06/2007
Last Update Date: 09/25/2021
Certification Date: 09/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

474 MACON EMBRO RD
MACON NC
27551-9285
US

IV. Provider business mailing address

PO BOX 2002
HENDERSON NC
27536-2002
US

V. Phone/Fax

Practice location:
  • Phone: 252-257-1380
  • Fax:
Mailing address:
  • Phone: 252-204-1381
  • Fax: 252-598-0051

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 NumberMHL093034
License Number StateNC

VIII. Authorized Official

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