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General NPI Number Information
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NPI Number | 1134383102
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Entity Type | Organization
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Legal Business Name | THE GUARDIAN LIGHT
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Dates
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Enumeration Date | 07/17/2008
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Last Update Date | 07/17/2008
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Provider Practice Location Address
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Address Line | 2101 MOUNTAIN RUN DR
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City | GLEN ALLEN
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State | VA
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Zip | 23060-2261
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Country | US
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Telephone | 804-475-3344
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Fax |
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Provider Business Mailing Address
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Address Line | 2101 MOUNTAIN RUN DR
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City | GLEN ALLEN
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State | VA
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Zip | 23060-2261
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Country | US
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Telephone | 804-475-3344
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Fax |
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | MS. JANICE MARIE BAILEY
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Credential | M.S.
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Telephone | 804-475-3344
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320800000X
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Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
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License Number | CLO-08-1104074
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License Number State | VA
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