Provider Demographics
NPI:1417386541
Name:GUARDIAN ANGEL HOME CARE AGENCY
Entity Type:Organization
Organization Name:GUARDIAN ANGEL HOME CARE AGENCY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARIAN
Authorized Official - Middle Name:F
Authorized Official - Last Name:FUNDERBURK
Authorized Official - Suffix:
Authorized Official - Credentials:BS
Authorized Official - Phone:704-948-5654
Mailing Address - Street 1:1801 N TRYON ST
Mailing Address - Street 2:SUITE 305B
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28206-2704
Mailing Address - Country:US
Mailing Address - Phone:704-948-5658
Mailing Address - Fax:
Practice Address - Street 1:1801 NORTH TRYON ST
Practice Address - Street 2:SUITE 305B
Practice Address - City:HUNTERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28070-2098
Practice Address - Country:US
Practice Address - Phone:704-948-5654
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-08
Last Update Date:2013-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC611521372Medicare UPIN