Provider Demographics
NPI:1093413585
Name:GUADALUPE LLC
Entity Type:Organization
Organization Name:GUADALUPE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SILVANA
Authorized Official - Middle Name:
Authorized Official - Last Name:CAMPOS
Authorized Official - Suffix:
Authorized Official - Credentials:ECT
Authorized Official - Phone:404-492-2093
Mailing Address - Street 1:696 WINDY HILL RD SE
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30080-1857
Mailing Address - Country:US
Mailing Address - Phone:404-492-2093
Mailing Address - Fax:
Practice Address - Street 1:696 WINDY HILL RD SE
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30080-1857
Practice Address - Country:US
Practice Address - Phone:404-492-2093
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-23
Last Update Date:2023-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No202C00000XAllopathic & Osteopathic PhysiciansIndependent Medical ExaminerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1144226135OtherPRIVATE PRACTICE
GA1780076182OtherPRIVATE PRACTICE