Provider Demographics
NPI:1346396793
Name:GUARDIAN ANGEL HEALTHCARE, LLC
Entity Type:Organization
Organization Name:GUARDIAN ANGEL HEALTHCARE, LLC
Other - Org Name:JEREMIAH'S PLACE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT - REGISTERED AGENT
Authorized Official - Prefix:MR
Authorized Official - First Name:CORNELIUS
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-257-9349
Mailing Address - Street 1:107 CURRIN LN
Mailing Address - Street 2:
Mailing Address - City:WARRENTON
Mailing Address - State:NC
Mailing Address - Zip Code:27589-2249
Mailing Address - Country:US
Mailing Address - Phone:252-257-9349
Mailing Address - Fax:252-492-9088
Practice Address - Street 1:314 S GARNETT ST
Practice Address - Street 2:SUITE 202
Practice Address - City:HENDERSON
Practice Address - State:NC
Practice Address - Zip Code:27536-4538
Practice Address - Country:US
Practice Address - Phone:252-492-9205
Practice Address - Fax:252-492-9088
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL091077320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7805648Medicaid