Provider Demographics
NPI:1952445090
Name:GUARDIAN ANGEL FAMILY CARE HOME, INC
Entity Type:Organization
Organization Name:GUARDIAN ANGEL FAMILY CARE HOME, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:VANESSA
Authorized Official - Middle Name:G
Authorized Official - Last Name:PACKINGHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-222-0114
Mailing Address - Street 1:1006 RICHMOND AVE
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27217-1525
Mailing Address - Country:US
Mailing Address - Phone:336-222-0114
Mailing Address - Fax:336-222-0114
Practice Address - Street 1:1006 RICHMOND AVE
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27217-1525
Practice Address - Country:US
Practice Address - Phone:336-222-0114
Practice Address - Fax:336-222-0114
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-19
Last Update Date:2012-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCFCL-001-118311Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311Z00000XNursing & Custodial Care FacilitiesCustodial Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7805761Medicaid