=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649699265
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANGEL GUARDIAN ASSISTED LIVING
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/10/2014
-----------------------------------------------------
Last Update Date | 05/21/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 280 BAHAMA DR
-----------------------------------------------------
City | MERRITT ISLAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32952-3605
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-848-0255
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 280 BAHAMA DR.
-----------------------------------------------------
City | MERRITT ISLAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32952
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-848-0255
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MS. ROSEANN J SIMONE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 321-223-8371
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | AL10561
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------