Provider Demographics
NPI:1962112060
Name:IMPERIAL GUARDIAN LLC
Entity type:Organization
Organization Name:IMPERIAL GUARDIAN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:ODOM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-692-4300
Mailing Address - Street 1:2413 RAYMOND DIEHL RD APT 2
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32309-3628
Mailing Address - Country:US
Mailing Address - Phone:850-692-4300
Mailing Address - Fax:850-668-8329
Practice Address - Street 1:2257 CLARA KEE BLVD
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32303-7135
Practice Address - Country:US
Practice Address - Phone:850-692-4300
Practice Address - Fax:850-668-5679
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-29
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty