Provider Demographics
NPI:1669092185
Name:GUILLERMO GUARDIOLA, JR. CRNA, PLLC
Entity type:Organization
Organization Name:GUILLERMO GUARDIOLA, JR. CRNA, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:GUILLERMO
Authorized Official - Middle Name:
Authorized Official - Last Name:GUARDIOLA
Authorized Official - Suffix:JR
Authorized Official - Credentials:CRNA
Authorized Official - Phone:214-683-7937
Mailing Address - Street 1:PO BOX 541736
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75054
Mailing Address - Country:US
Mailing Address - Phone:214-683-7937
Mailing Address - Fax:
Practice Address - Street 1:6201 OVERTON RIDGE BLVD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-3613
Practice Address - Country:US
Practice Address - Phone:817-222-8300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-24
Last Update Date:2020-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0Medicaid