Provider Demographics
NPI:1548315203
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:DR
Authorized Official - First Name:PAULETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:BUTLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-732-8473
Mailing Address - Street 1:41 S HALL RD
Mailing Address - Street 2:
Mailing Address - City:MORTON
Mailing Address - State:MS
Mailing Address - Zip Code:39117-8057
Mailing Address - Country:US
Mailing Address - Phone:601-732-8473
Mailing Address - Fax:601-732-8037
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:601-782-4918
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS07565173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03920570Medicaid
MS03920570Medicaid