Provider Demographics
NPI:1093109951
Name:GUARDIAN THERAPEUTIC CENTER
Entity Type:Organization
Organization Name:GUARDIAN THERAPEUTIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:OBATUASE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-394-9696
Mailing Address - Street 1:3350 WILKENS AVE
Mailing Address - Street 2:SUITE-302
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21229-4600
Mailing Address - Country:US
Mailing Address - Phone:410-394-9696
Mailing Address - Fax:443-552-3748
Practice Address - Street 1:3350 WILKENS AVE
Practice Address - Street 2:SUITE-302
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21229-4600
Practice Address - Country:US
Practice Address - Phone:410-394-9696
Practice Address - Fax:443-552-3748
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-27
Last Update Date:2015-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDMH-1549261QR0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)