MEDICARE: GUARDIAN ANGELS PRIVATE HOMECARE 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	311Z00000X	Custodial Care Facility
2	251E00000X	Home Health Agency

General Provider Information

NPI Number	:	1912282039
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GUARDIAN ANGELS PRIVATE HOMECARE LLC

Provider Business Mailing Address
First Line	:	207 KITE LAKE RD
Second Line	:
City	:	FAYETTEVILLE
State	:	GA
Zip	:	30214-9608
Country	:	US
Telephone Number	:	770-666-4401
Fax Number	:

Provider Business Practice Location Address
First Line	:	207 KITE LAKE RD
Second Line	:
City	:	FAYETTEVILLE
State	:	GA
Zip	:	30214-9608
Country	:	US
Telephone Number	:	770-666-4401
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MS. BRITTANEY SHONTERIA HESTER
Credential	:
Telephone Number	:	770-666-4401

Provider Enumeration Date	:	10/20/2011
Last Update Date	:	10/20/2011

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