Provider Demographics
NPI:1154381267
Name:GUARDIAN ANGEL HOME HEALTH AGENCY, INC.
Entity type:Organization
Organization Name:GUARDIAN ANGEL HOME HEALTH AGENCY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:OLEG
Authorized Official - Middle Name:
Authorized Official - Last Name:PONOMARENKO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-581-0244
Mailing Address - Street 1:980 ENCHANTED WAY STE 206
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93065-0913
Mailing Address - Country:US
Mailing Address - Phone:805-581-0244
Mailing Address - Fax:805-581-0286
Practice Address - Street 1:980 ENCHANTED WAY STE 206
Practice Address - Street 2:
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93065-0913
Practice Address - Country:US
Practice Address - Phone:805-581-0244
Practice Address - Fax:805-581-0286
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-23
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA050000588251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHHA08299FMedicaid
CA058299Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER