Healthcare Provider Details

I. General information

NPI: 1447691316
Provider Name (Legal Business Name): GUARDIAN HEALTHCARE PROVIDER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2013
Last Update Date: 07/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 S FOCH ST #3
TRUTH OR CONSEQUENCES NM
87901-3330
US

IV. Provider business mailing address

300 S FOCH ST #3
TRUTH OR CONSEQUENCES NM
87901-3330
US

V. Phone/Fax

Practice location:
  • Phone: 347-595-0692
  • Fax:
Mailing address:
  • Phone: 347-595-0692
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number4042
License Number StateNM

VIII. Authorized Official

Name: MS. GENELYN GERONIMO ACACIO
Title or Position: PHYSICAL THERAPIST
Credential:
Phone: 347-595-0692