Provider Demographics
NPI:1740317858
Name:GUARDIA, VINCENT CHARLES (MED)
Entity type:Individual
Prefix:MR
First Name:VINCENT
Middle Name:CHARLES
Last Name:GUARDIA
Suffix:
Gender:M
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 39
Mailing Address - Street 2:HCA MEDICAL BILLING
Mailing Address - City:MARSTON MILLS
Mailing Address - State:MA
Mailing Address - Zip Code:02648
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:947 RT 6A
Practice Address - Street 2:
Practice Address - City:YARMOUTH PORT
Practice Address - State:MA
Practice Address - Zip Code:02675
Practice Address - Country:US
Practice Address - Phone:508-362-3609
Practice Address - Fax:508-362-3609
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA112101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1891596Medicaid