Provider Demographics
NPI:1447691316
Name:GUARDIAN HEALTHCARE PROVIDER
Entity type:Organization
Organization Name:GUARDIAN HEALTHCARE PROVIDER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:GENELYN
Authorized Official - Middle Name:GERONIMO
Authorized Official - Last Name:ACACIO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:347-595-0692
Mailing Address - Street 1:300 S FOCH ST
Mailing Address - Street 2:#3
Mailing Address - City:TRUTH OR CONSEQUENCES
Mailing Address - State:NM
Mailing Address - Zip Code:87901-3330
Mailing Address - Country:US
Mailing Address - Phone:347-595-0692
Mailing Address - Fax:
Practice Address - Street 1:300 S FOCH ST
Practice Address - Street 2:#3
Practice Address - City:TRUTH OR CONSEQUENCES
Practice Address - State:NM
Practice Address - Zip Code:87901-3330
Practice Address - Country:US
Practice Address - Phone:347-595-0692
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-08
Last Update Date:2013-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM4042314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility