1104323070 NPI number — GOLDEN YEARS ADULT DAYCARE OF JACKSON LLC

Table of content: (NPI 1104323070)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104323070 NPI number — GOLDEN YEARS ADULT DAYCARE OF JACKSON LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GOLDEN YEARS ADULT DAYCARE OF JACKSON 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:
Provider Other Organization Name Type Code:
6
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:
1104323070
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/12/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
155 CARRIAGE DR SUITE A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSON
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38305
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
731-506-9068
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1118 WHITEHALL STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSON
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38301-3730
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
731-736-2440
Provider Business Practice Location Address Fax Number:
731-736-3655
Provider Enumeration Date:
04/09/2018

Additional Information

Authorized Official

Authorized Official Last Name:
DOUGLAS
Authorized Official First Name:
BRENDA
Authorized Official Middle Name:
F
Authorized Official Title or Position:
MANGER
Authorized Official Telephone Number:
731-267-0818

Provider Taxonomy Codes

  • Taxonomy code: 261QA0600X , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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