Provider Demographics
NPI:1669070215
Name:MY GUARDIAN ANGEL FAMILY CARE HOME
Entity type:Organization
Organization Name:MY GUARDIAN ANGEL FAMILY CARE HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VERNON
Authorized Official - Middle Name:
Authorized Official - Last Name:BRYANT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-813-1939
Mailing Address - Street 1:2001 VERNON ROAD
Mailing Address - Street 2:
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:NC
Mailing Address - Zip Code:27801-6348
Mailing Address - Country:US
Mailing Address - Phone:252-977-3368
Mailing Address - Fax:252-977-3368
Practice Address - Street 1:514 COKEY ROAD
Practice Address - Street 2:
Practice Address - City:ROCKY MOUNT
Practice Address - State:NC
Practice Address - Zip Code:27801
Practice Address - Country:US
Practice Address - Phone:252-977-3368
Practice Address - Fax:252-977-3368
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-15
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
No311Z00000XNursing & Custodial Care FacilitiesCustodial Care Facility
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No347C00000XTransportation ServicesPrivate Vehicle