Provider Demographics
NPI:1053593574
Name:GUARDIAN ANGELS INDEPENDENT LIVING SERVICES
Entity type:Organization
Organization Name:GUARDIAN ANGELS INDEPENDENT LIVING SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHNNY
Authorized Official - Middle Name:BOB
Authorized Official - Last Name:ROSS
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:225-922-4466
Mailing Address - Street 1:1821 WOODDALE CT
Mailing Address - Street 2:SUITE 104
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70806-1535
Mailing Address - Country:US
Mailing Address - Phone:225-922-4466
Mailing Address - Fax:225-922-4420
Practice Address - Street 1:1821 WOODDALE CT
Practice Address - Street 2:SUITE 104
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70806-1535
Practice Address - Country:US
Practice Address - Phone:225-922-4466
Practice Address - Fax:225-922-4420
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-27
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA14010385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1019950Medicaid