MEDICARE: GUARDIAN ANGELS GROUP HOME LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	310400000X	Assisted Living Facility	139074	TX
2	311500000X	Alzheimer Center (Dementia Center)	103113	TX

General Provider Information

NPI Number	:	1194134106
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GUARDIAN ANGELS GROUP HOME LLC

Provider Business Mailing Address
First Line	:	426 BIRCH LN
Second Line	:
City	:	RICHARDSON
State	:	TX
Zip	:	75081-5526
Country	:	US
Telephone Number	:	469-401-7301
Fax Number	:	972-234-4041

Provider Business Practice Location Address
First Line	:	426 BIRCH LN
Second Line	:
City	:	RICHARDSON
State	:	TX
Zip	:	75081-5526
Country	:	US
Telephone Number	:	469-401-7301
Fax Number	:	972-234-4041

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	JOSHUA KARIUKI
Credential	:
Telephone Number	:	469-401-7301

Provider Enumeration Date	:	08/05/2014
Last Update Date	:	08/05/2014

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