=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467129452
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GUARDIAN HEALTH LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/26/2021
-----------------------------------------------------
Last Update Date | 02/18/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 300 TAMIAMI TRL S UNIT 1
-----------------------------------------------------
City | VENICE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34285-2422
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-303-5713
-----------------------------------------------------
Fax | 941-786-3914
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 300 TAMIAMI TRL S UNIT 1
-----------------------------------------------------
City | VENICE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34285-2422
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-303-5713
-----------------------------------------------------
Fax | 941-786-3914
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | GAVIN WHAPSHARE
-----------------------------------------------------
Credential | DO
-----------------------------------------------------
Telephone | 941-305-5713
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------