Provider Demographics
NPI:1811374804
Name:GUARDIAN COMMUNITY REHABILITATION SERVICES
Entity Type:Organization
Organization Name:GUARDIAN COMMUNITY REHABILITATION SERVICES
Other - Org Name:NESBURG INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:OLUWOLE
Authorized Official - Last Name:OBATUASE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-800-4572
Mailing Address - Street 1:11240 REISTERSTOWN RD
Mailing Address - Street 2:SUITE C-5
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117-1965
Mailing Address - Country:US
Mailing Address - Phone:410-800-4572
Mailing Address - Fax:410-286-1923
Practice Address - Street 1:11240 REISTERSTOWN RD
Practice Address - Street 2:SUITE C-5
Practice Address - City:OWINGS MILLS
Practice Address - State:MD
Practice Address - Zip Code:21117-1965
Practice Address - Country:US
Practice Address - Phone:410-800-4572
Practice Address - Fax:410-286-1923
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-29
Last Update Date:2015-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR3420R251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD2224003P0001Medicaid