MEDICARE: GOLDEN GUARDIANS CARE AGENCY, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	253Z00000X	In Home Supportive Care Agency

General Provider Information

NPI Number	:	1124688312
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GOLDEN GUARDIANS CARE AGENCY, LLC

Provider Business Mailing Address
First Line	:	2542 SE OAKLYN ST
Second Line	:
City	:	PORT ST LUCIE
State	:	FL
Zip	:	34984-5228
Country	:	US
Telephone Number	:	772-777-2381
Fax Number	:

Provider Business Practice Location Address
First Line	:	2542 SE OAKLYN ST
Second Line	:
City	:	PORT SAINT LUCIE
State	:	FL
Zip	:	34984-5228
Country	:	US
Telephone Number	:	772-777-2381
Fax Number	:

Authorized Official
Title or Position	:	VICE PRESIDENT
Name	:	CHANNEL HARRIS-GOWDIE
Credential	:
Telephone Number	:	772-626-5948

Provider Enumeration Date	:	06/19/2019
Last Update Date	:	03/28/2022

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