Provider Demographics
NPI:1730825787
Name:GUARDIAN ANGEL SENIOR CARE, LLC
Entity type:Organization
Organization Name:GUARDIAN ANGEL SENIOR CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARGARET
Authorized Official - Middle Name:
Authorized Official - Last Name:TISDALE FITTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-354-3500
Mailing Address - Street 1:511 GILLAND AVE
Mailing Address - Street 2:
Mailing Address - City:KINGSTREE
Mailing Address - State:SC
Mailing Address - Zip Code:29556-3204
Mailing Address - Country:US
Mailing Address - Phone:770-329-3555
Mailing Address - Fax:
Practice Address - Street 1:831 N EASTLAND AVE
Practice Address - Street 2:
Practice Address - City:KINGSTREE
Practice Address - State:SC
Practice Address - Zip Code:29556-2555
Practice Address - Country:US
Practice Address - Phone:843-354-3500
Practice Address - Fax:843-354-3500
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-11
Last Update Date:2022-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCEX0787Medicaid