Provider Demographics
NPI:1558766329
Name:CARE DIVINE OF GUARDIAN ANGEL, LLC
Entity Type:Organization
Organization Name:CARE DIVINE OF GUARDIAN ANGEL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MARGARET
Authorized Official - Middle Name:C
Authorized Official - Last Name:IKE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:915-307-4234
Mailing Address - Street 1:1537 N. ZARAGOZA RD.
Mailing Address - Street 2:SUITE 2-A
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79936
Mailing Address - Country:US
Mailing Address - Phone:915-307-4234
Mailing Address - Fax:915-307-4027
Practice Address - Street 1:3135 TRAWOOD DR
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79936
Practice Address - Country:US
Practice Address - Phone:915-307-4234
Practice Address - Fax:915-307-4027
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-23
Last Update Date:2022-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX147231864Medicaid