Provider Demographics
NPI:1376691519
Name:GUARDIAN ANGEL HEALTHCARE, LLC
Entity Type:Organization
Organization Name:GUARDIAN ANGEL HEALTHCARE, LLC
Other - Org Name:THORPE'S PLACE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENTREGISTERED 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:252-204-1381
Mailing Address - Street 1:PO BOX 2002
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NC
Mailing Address - Zip Code:27536-2002
Mailing Address - Country:US
Mailing Address - Phone:252-204-1381
Mailing Address - Fax:
Practice Address - Street 1:448 SUMMIT RD
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NC
Practice Address - Zip Code:27537-4529
Practice Address - Country:US
Practice Address - Phone:252-204-1381
Practice Address - Fax:252-598-0051
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-06
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6603871Medicaid