Provider Demographics
NPI:1053456459
Name:GUARDIAN ANGEL HOSPICE, INC
Entity Type:Organization
Organization Name:GUARDIAN ANGEL HOSPICE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:PAULETTE
Authorized Official - Middle Name:H
Authorized Official - Last Name:BUTLER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:601-732-8473
Mailing Address - Street 1:41 S HALL RD
Mailing Address - Street 2:
Mailing Address - City:MORTON
Mailing Address - State:MS
Mailing Address - Zip Code:39117-8057
Mailing Address - Country:US
Mailing Address - Phone:601-732-8473
Mailing Address - Fax:601-732-8037
Practice Address - Street 1:41 S HALL RD
Practice Address - Street 2:
Practice Address - City:MORTON
Practice Address - State:MS
Practice Address - Zip Code:39117-8057
Practice Address - Country:US
Practice Address - Phone:601-732-8473
Practice Address - Fax:601-732-8037
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2007-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS059315D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315D00000XNursing & Custodial Care FacilitiesHospice, Inpatient
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00770357Medicaid
MS00770357Medicaid