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General NPI Number Information
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NPI Number | 1942571625
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Entity Type | Organization
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Legal Business Name | LOWES GUARDIAN ANGEL LLC
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Dates
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Enumeration Date | 01/26/2012
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Last Update Date | 01/26/2012
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Provider Practice Location Address
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Address Line | 7056 EUNICE DR.
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City | RIVERDALE
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State | GA
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Zip | 30274
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Country | US
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Telephone | 678-586-3171
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Fax |
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Provider Business Mailing Address
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Address Line | 7056 EUNICE DR
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City | RIVERDALE
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State | GA
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Zip | 30274-3152
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Country | US
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Telephone | 678-586-3171
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Fax |
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Authorized Official
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Title or Position | DDP
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Name | MR. GLENN ALAN LOWE
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Credential | BA
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Telephone | 404-808-4859
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320900000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
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License Number | 251911340
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License Number State | GA
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