Provider Demographics
NPI:1679924195
Name:GUARDIAN ANGELS OF THE UPSTATE
Entity type:Organization
Organization Name:GUARDIAN ANGELS OF THE UPSTATE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JIMETTA
Authorized Official - Middle Name:
Authorized Official - Last Name:LITTLEJOHN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-242-7633
Mailing Address - Street 1:117 FAIRVIEW POINTE DR
Mailing Address - Street 2:
Mailing Address - City:SIMPSONVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29681-3223
Mailing Address - Country:US
Mailing Address - Phone:404-242-7633
Mailing Address - Fax:
Practice Address - Street 1:117 FAIRVIEW POINTE DR
Practice Address - Street 2:
Practice Address - City:SIMPSONVILLE
Practice Address - State:SC
Practice Address - Zip Code:29681
Practice Address - Country:US
Practice Address - Phone:404-242-7633
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-27
Last Update Date:2016-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes305S00000XManaged Care OrganizationsPoint of ServiceGroup - Multi-Specialty
No164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Multi-Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
No251E00000XAgenciesHome Health
No253Z00000XAgenciesIn Home Supportive Care
No302F00000XManaged Care OrganizationsExclusive Provider Organization
No305R00000XManaged Care OrganizationsPreferred Provider Organization