Healthcare Provider Details

I. General information

NPI: 1821704727
Provider Name (Legal Business Name): LIFE GUARDIAN ANGELS HEALTHCARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2023
Last Update Date: 07/24/2023
Certification Date: 07/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 HOLIDAY PLAZA DR STE 184
MATTESON IL
60443-2241
US

IV. Provider business mailing address

906 EAGLE POINT DR
MATTESON IL
60443-1987
US

V. Phone/Fax

Practice location:
  • Phone: 708-646-3965
  • Fax:
Mailing address:
  • Phone: 708-646-3965
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: TESHON OGUNDELE
Title or Position: OWNER/PRESIDENT
Credential:
Phone: 773-954-4385