MEDICARE: GUARDIAN CARE SERVICES 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	261QD1600X	Developmental Disabilities Clinic/Center

General Provider Information

NPI Number	:	1922604982
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GUARDIAN CARE SERVICES LLC

Provider Business Mailing Address
First Line	:	1102 RAY CHARLES BLVD UNIT 619
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33602-3059
Country	:	US
Telephone Number	:	813-863-7570
Fax Number	:

Provider Business Practice Location Address
First Line	:	1102 RAY CHARLES BLVD UNIT 619
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33602-3059
Country	:	US
Telephone Number	:	813-863-7570
Fax Number	:

Authorized Official
Title or Position	:	OWNER/PROVIDER
Name	:	MISS EBONY MAIA WHITAKER
Credential	:
Telephone Number	:	813-863-7570

Provider Enumeration Date	:	12/07/2020
Last Update Date	:	12/07/2020

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