Provider Demographics
NPI:1518457209
Name:GUARDIAN ANGELS SUPPORTED LIVING LLC
Entity Type:Organization
Organization Name:GUARDIAN ANGELS SUPPORTED LIVING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CARRIE
Authorized Official - Middle Name:
Authorized Official - Last Name:HARDAWAY
Authorized Official - Suffix:
Authorized Official - Credentials:LPN
Authorized Official - Phone:573-575-1015
Mailing Address - Street 1:1006 LINN ST
Mailing Address - Street 2:
Mailing Address - City:SIKESTON
Mailing Address - State:MO
Mailing Address - Zip Code:63801-2223
Mailing Address - Country:US
Mailing Address - Phone:573-471-1412
Mailing Address - Fax:573-481-4432
Practice Address - Street 1:1006 LINN ST
Practice Address - Street 2:
Practice Address - City:SIKESTON
Practice Address - State:MO
Practice Address - Zip Code:63801-2223
Practice Address - Country:US
Practice Address - Phone:573-471-1412
Practice Address - Fax:573-481-4432
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-17
Last Update Date:2019-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No372500000XNursing Service Related ProvidersChore ProviderGroup - Multi-Specialty
No385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child
No385HR2065XRespite Care FacilityRespite CareRespite Care, Physical Disabilities, Child