Healthcare Provider Details

I. General information

NPI: 1588477863
Provider Name (Legal Business Name): GUARDIAN COVE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2025
Last Update Date: 01/30/2025
Certification Date: 01/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11205 CREEKVIEW DR
RIVERVIEW FL
33569-5157
US

IV. Provider business mailing address

13611 ASHLAR SLATE PL
RIVERVIEW FL
33579-2140
US

V. Phone/Fax

Practice location:
  • Phone: 727-337-0108
  • Fax:
Mailing address:
  • Phone: 813-401-0612
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code253J00000X
TaxonomyFoster Care Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: DR. IJEOMA MUFORO
Title or Position: PROGRAM DIRECTOR
Credential: PHARMD
Phone: 813-401-0612