Provider Demographics
NPI:1972141612
Name:GUARDADO, JESUS (CAREGIVER)
Entity type:Individual
Prefix:
First Name:JESUS
Middle Name:
Last Name:GUARDADO
Suffix:
Gender:M
Credentials:CAREGIVER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2167 INNWOOD DR SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49508-5036
Mailing Address - Country:US
Mailing Address - Phone:661-675-9777
Mailing Address - Fax:
Practice Address - Street 1:2167 INNWOOD DR SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49508-5036
Practice Address - Country:US
Practice Address - Phone:661-675-9777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-12
Last Update Date:2019-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAF410400507251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health