Provider Demographics
NPI:1578823928
Name:GUARDIAN CARE LLC.
Entity Type:Organization
Organization Name:GUARDIAN CARE LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANNA
Authorized Official - Middle Name:W
Authorized Official - Last Name:OBERHOUSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-415-9533
Mailing Address - Street 1:408 STONEWATER CV
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-4405
Mailing Address - Country:US
Mailing Address - Phone:601-415-9533
Mailing Address - Fax:
Practice Address - Street 1:104 W RAILROAD AVE N
Practice Address - Street 2:
Practice Address - City:CRYSTAL SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39059-2154
Practice Address - Country:US
Practice Address - Phone:601-415-9533
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-19
Last Update Date:2016-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09574731Medicaid