Healthcare Provider Details

I. General information

NPI: 1104511831
Provider Name (Legal Business Name): GUARDIAN CONSORTIUM GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2023
Last Update Date: 08/08/2023
Certification Date: 08/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5907 COVINGTON RD
FORT WAYNE IN
46804-5857
US

IV. Provider business mailing address

4611 N 615 W
HUNTINGTON IN
46750-8921
US

V. Phone/Fax

Practice location:
  • Phone: 260-766-6274
  • Fax:
Mailing address:
  • Phone: 317-650-9031
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: SHAUNNA F MINNICK
Title or Position: OWNER/OPERATOR
Credential: RN
Phone: 317-650-9031