Provider Demographics
NPI:1740833391
Name:GUARDIAN ANGEL HEALTHCARE II, INC.
Entity type:Organization
Organization Name:GUARDIAN ANGEL HEALTHCARE II, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:PAULETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:BUTLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-782-9997
Mailing Address - Street 1:347 MAGNOLIA DR
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:MS
Mailing Address - Zip Code:39153-6011
Mailing Address - Country:US
Mailing Address - Phone:601-782-9997
Mailing Address - Fax:601-782-5655
Practice Address - Street 1:347 MAGNOLIA DR
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:MS
Practice Address - Zip Code:39153-6011
Practice Address - Country:US
Practice Address - Phone:601-782-9997
Practice Address - Fax:601-782-5655
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GUARDIAN ANGEL HEALTHCARE II, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-07-23
Last Update Date:2019-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes275N00000XHospital UnitsMedicare Defined Swing Bed Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09156818Medicaid