MEDICARE: MR. WILLIE B GOLDEN JR. CNA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	376K00000X	Nurse's Aide	49019812782	IN

General Provider Information

NPI Number	:	1902923956
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. WILLIE B GOLDEN JR. CNA

Provider Business Mailing Address
First Line	:	5706 RENN LN
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46254-2300
Country	:	US
Telephone Number	:	317-387-1363
Fax Number	:

Provider Business Practice Location Address
First Line	:	3011 N FRANKLIN RD
Second Line	:	SMC CORPORATION OF AMERICA
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46226-6308
Country	:	US
Telephone Number	:	317-603-3668
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/23/2007
Last Update Date	:	07/08/2007

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