Provider Demographics
NPI:1144772435
Name:GUARDIAN ANGELS HOSPICE,LLC
Entity Type:Organization
Organization Name:GUARDIAN ANGELS HOSPICE,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TAMEKIA
Authorized Official - Middle Name:
Authorized Official - Last Name:FULLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:470-242-5682
Mailing Address - Street 1:3469 LAWRENCEVILLE HWY
Mailing Address - Street 2:203
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-5888
Mailing Address - Country:US
Mailing Address - Phone:470-242-5682
Mailing Address - Fax:
Practice Address - Street 1:3469 LAWRENCEVILLE HWY
Practice Address - Street 2:203
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-5888
Practice Address - Country:US
Practice Address - Phone:470-242-5682
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GUARDIAN ANGELS HOSPICE,LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-11-02
Last Update Date:2016-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0440430H251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA0440430HMedicare UPIN