Provider Demographics
NPI:1720136963
Name:GUARDIAN ANGEL HEALTHCARE
Entity Type:Organization
Organization Name:GUARDIAN ANGEL HEALTHCARE
Other - Org Name:WILLOW ROAD FACILITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT REGISTERED AGENT
Authorized Official - Prefix:MR
Authorized Official - First Name:CORNELIUS
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-204-1381
Mailing Address - Street 1:PO BOX 2002
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NC
Mailing Address - Zip Code:27536-2002
Mailing Address - Country:US
Mailing Address - Phone:252-204-1381
Mailing Address - Fax:252-598-0051
Practice Address - Street 1:474 MACON EMBRO RD
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:NC
Practice Address - Zip Code:27551-9285
Practice Address - Country:US
Practice Address - Phone:252-257-1380
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-06
Last Update Date:2021-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251S00000X
NCMHL093034320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7804755Medicaid