=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093253692
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GUARDIAN ANGELS FOR SENIORS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/03/2017
-----------------------------------------------------
Last Update Date | 02/03/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2555 NE LOOP 410 #2302
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78217-5717
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-763-0459
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2555 NE LOOP 410 #2302
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78217-5717
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-763-0459
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MR. MUKOSOLU EGWIM
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 210-763-0459
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------