Provider Demographics
NPI:1952830143
Name:GUARDADO, MARTHA (311ZA0620X)
Entity Type:Individual
Prefix:MISS
First Name:MARTHA
Middle Name:
Last Name:GUARDADO
Suffix:
Gender:F
Credentials:311ZA0620X
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5689 GENTIAN CT SE
Mailing Address - Street 2:
Mailing Address - City:KENTWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49508-6403
Mailing Address - Country:US
Mailing Address - Phone:616-325-0222
Mailing Address - Fax:
Practice Address - Street 1:5689 GENTIAN CT SE
Practice Address - Street 2:
Practice Address - City:KENTWOOD
Practice Address - State:MI
Practice Address - Zip Code:49508-6403
Practice Address - Country:US
Practice Address - Phone:616-325-0222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-09
Last Update Date:2017-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAF410381126311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home