1396103966 NPI number — GOLDEN CARRIAGE RETIREMENT HOME

Table of content: MS. MYRIKLE ALESIA JACKSON BACHELOR OF SCIENCE (NPI 1154826444)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396103966 NPI number — GOLDEN CARRIAGE RETIREMENT HOME

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GOLDEN CARRIAGE RETIREMENT HOME
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:
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:
1396103966
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/10/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
926 MELLER WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORLANDO
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32825-3801
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
321-356-9636
Provider Business Mailing Address Fax Number:
407-679-5325

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
926 MELLER WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ORLANDO
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32825-3801
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
321-356-9636
Provider Business Practice Location Address Fax Number:
407-679-5325
Provider Enumeration Date:
02/10/2016

Additional Information

Authorized Official

Authorized Official Last Name:
PUN
Authorized Official First Name:
MARIE
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/ADMINISTRATOR
Authorized Official Telephone Number:
321-356-9636

Provider Taxonomy Codes

  • Taxonomy code: 310400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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