Provider Demographics
NPI:1306650023
Name:THE GUARDIAN GLOW LLC
Entity type:Organization
Organization Name:THE GUARDIAN GLOW LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:GLORY
Authorized Official - Middle Name:GODSON
Authorized Official - Last Name:KOMBE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-385-9163
Mailing Address - Street 1:855 ROMAN RD
Mailing Address - Street 2:
Mailing Address - City:WAUKEE
Mailing Address - State:IA
Mailing Address - Zip Code:50263-8075
Mailing Address - Country:US
Mailing Address - Phone:312-385-9163
Mailing Address - Fax:
Practice Address - Street 1:855 ROMAN RD
Practice Address - Street 2:
Practice Address - City:WAUKEE
Practice Address - State:IA
Practice Address - Zip Code:50263-8075
Practice Address - Country:US
Practice Address - Phone:312-385-9163
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-02-04
Last Update Date:2025-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities