Provider Demographics
NPI:1891121992
Name:GUARDIAN HEALTH CARE PROVIDER INC.
Entity Type:Organization
Organization Name:GUARDIAN HEALTH CARE PROVIDER INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:GENELYN
Authorized Official - Middle Name:GERONIMO
Authorized Official - Last Name:ACACIO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:347-595-0692
Mailing Address - Street 1:300 S FOCH ST
Mailing Address - Street 2:#3
Mailing Address - City:TRUTH OR CONSEQUENCES
Mailing Address - State:NM
Mailing Address - Zip Code:87901-3330
Mailing Address - Country:US
Mailing Address - Phone:347-595-0692
Mailing Address - Fax:
Practice Address - Street 1:105 WESTPARK DR STE 100
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:TN
Practice Address - Zip Code:37027-5319
Practice Address - Country:US
Practice Address - Phone:800-365-5787
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-20
Last Update Date:2013-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM4042314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility