1417497306 NPI number — GOLDEN YEARS HEALTHCARE LLC

Table of content: (NPI 1417497306)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417497306 NPI number — GOLDEN YEARS HEALTHCARE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GOLDEN YEARS HEALTHCARE LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
GOLDEN YEARS HOME & ADULT CARE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417497306
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/09/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 372
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARKS
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38646-0372
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-326-0449
Provider Business Mailing Address Fax Number:
662-326-3586

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
207 CHESTNUT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARKS
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38646-1212
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-326-0449
Provider Business Practice Location Address Fax Number:
662-326-3585
Provider Enumeration Date:
02/27/2017

Additional Information

Authorized Official

Authorized Official Last Name:
WRIGHT HANKINS
Authorized Official First Name:
PATRICIA
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
662-326-3585

Provider Taxonomy Codes

  • Taxonomy code: 251C00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251J00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 253Z00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QA0600X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 385H00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 385HR2055X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1417497306 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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