Divine Guardian LLC

Primary specialty

Community Based Hospice Care AgencyTaxonomy code 251G00000X

Legal business name

DIVINE GUARDIAN LLC

Practice address

2321 4TH St Ste 210
Tucker, GA 30084-8516

Phone

(404) 513-9330

NPI assigned

Jul 9, 2020

Last updated

Jul 9, 2020By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Miranda Eskridge

Title

Owner

Phone

(404) 513-9330

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in GA

Enrollment records 1

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1609494327. Details of each certification follow.

• CCN 851582 Hospice · Active · Details

Hospice certification: CCN 851582

Legal name

DIVINE GUARDIAN LLC

Certification status

Active

Provider type (POS)

Hospice

Participating since

Sep 26, 2023

Last certification

Sep 26, 2023

Organization structure

LLCProprietary

Incorporated

Jun 26, 2020 in GA

Enrollment address

2321 4TH St
Ste 210
Tucker, GA 30084-8516

Listed as

Divine Guardian, LLCCCN 851582 · All quality measures

Certified

Sep 26, 2023

Medicare certification status

ActiveFrom the Provider of Services file

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

Locations

All disclosed owners & managing parties 2

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

Affiliated clinicians 1

Clinicians who list this facility as an affiliation in Medicare Care Compare.

• Robert David Vichich, M.D.

  • Emergency Medicine Physician
  • Minneapolis, MN
  • NPI 1780983569

  Hospice

  Care Compare affiliation

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1594252800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1594252800000",
    "number": "1609494327",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2321 4TH ST STE 210",
            "city": "TUCKER",
            "state": "GA",
            "postal_code": "300848516",
            "telephone_number": "404-513-9330"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2321 4TH ST STE 210",
            "city": "TUCKER",
            "state": "GA",
            "postal_code": "300848516",
            "telephone_number": "404-513-9330"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "DIVINE GUARDIAN LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2020-07-09",
        "last_updated": "2020-07-09",
        "certification_date": "2020-07-09",
        "status": "A",
        "authorized_official_last_name": "ESKRIDGE",
        "authorized_official_first_name": "MIRANDA",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "404-513-9330"
    },
    "taxonomies": [
        {
            "code": "251G00000X",
            "taxonomy_group": "",
            "desc": "Hospice Care, Community Based",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Salman Noorali Dewani
• Matthew Dewitt
• Thomas J Difulco, M.D.
• Discreet, Nemt Service Providers
• Discreet, Nemt Service Providers, LLC (Discreet, Nemt Service Providers Network)
• Divine Wellness
• Allison Dixon, LMSW
• Stephanie Dixon, M.S. CCC-SLP
• Ashley Dolphus, PHARMD
• S Domingo, LMT

• Community Based Hospice Care Agency in Tucker, GA
• Providers in Tucker, GA by specialty
• Community Based Hospice Care Agency in Georgia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 9, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; facility enrollments, owners and changes of ownership; Provider of Services certification data.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.