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General NPI Number Information
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NPI Number | 1962112060
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Entity Type | Organization
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Legal Business Name | IMPERIAL GUARDIAN LLC
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Dates
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Enumeration Date | 11/29/2022
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Last Update Date | 07/10/2023
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Provider Practice Location Address
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Address Line | 2257 CLARA KEE BLVD
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City | TALLAHASSEE
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State | FL
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Zip | 32303-7135
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Country | US
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Telephone | 850-692-4300
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Fax | 850-668-5679
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Provider Business Mailing Address
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Address Line | 2413 RAYMOND DIEHL RD APT 2
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City | TALLAHASSEE
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State | FL
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Zip | 32309-3628
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Country | US
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Telephone | 850-692-4300
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Fax | 850-668-8329
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Authorized Official
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Title or Position | OWNER
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Name | ANNIE ODOM
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Credential |
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Telephone | 850-692-4300
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 374U00000X
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Taxonomy Name | Home Health Aide
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License Number |
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License Number State |
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