Provider Demographics
NPI:1942571625
Name:LOWES GUARDIAN ANGEL LLC
Entity Type:Organization
Organization Name:LOWES GUARDIAN ANGEL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DDP
Authorized Official - Prefix:MR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:LOWE
Authorized Official - Suffix:
Authorized Official - Credentials:BA
Authorized Official - Phone:404-808-4859
Mailing Address - Street 1:7056 EUNICE DR
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30274-3152
Mailing Address - Country:US
Mailing Address - Phone:678-586-3171
Mailing Address - Fax:
Practice Address - Street 1:7056 EUNICE DR.
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30274
Practice Address - Country:US
Practice Address - Phone:678-586-3171
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-26
Last Update Date:2012-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA251911340320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA251911340OtherDBHDD DEVELOPMENTAL DISABILITIES PROVIDER