Healthcare Provider Details

I. General information

NPI: 1295408763
Provider Name (Legal Business Name): LIFEGUIDE FAMILY PRACTICE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2021
Last Update Date: 07/29/2021
Certification Date: 06/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

656 INDIAN TRAIL LILBURN RD NW STE 208
LILBURN GA
30047-6872
US

IV. Provider business mailing address

656 INDIAN TRAIL LILBURN RD NW STE 208
LILBURN GA
30047-6872
US

V. Phone/Fax

Practice location:
  • Phone: 770-557-1079
  • Fax:
Mailing address:
  • Phone: 770-557-1079
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251F00000X
TaxonomyHome Infusion Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QI0500X
TaxonomyInfusion Therapy Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code261QR1100X
TaxonomyResearch Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. OLUKAYODE AGBEYOMI
Title or Position: CEO
Credential:
Phone: 678-517-7425