MEDICARE: GUARDIAN ANGEL HEALTHCARE, 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	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1295308484
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GUARDIAN ANGEL HEALTHCARE, LLC

Provider Business Mailing Address
First Line	:	PO BOX 2002
Second Line	:
City	:	HENDERSON
State	:	NC
Zip	:	27536-2002
Country	:	US
Telephone Number	:	252-572-4005
Fax Number	:	252-598-0051

Provider Business Practice Location Address
First Line	:	119 BYNUM PL
Second Line	:
City	:	NORLINA
State	:	NC
Zip	:	27563-9139
Country	:	US
Telephone Number	:	252-204-1381
Fax Number	:	252-598-0051

Authorized Official
Title or Position	:	PRESIDENT/CEO
Name	:	CORNELIUS WILLIAMS
Credential	:	BA
Telephone Number	:	252-572-4005

Provider Enumeration Date	:	07/23/2021
Last Update Date	:	09/06/2023

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