Healthcare Provider Details

I. General information

NPI: 1740222801
Provider Name (Legal Business Name): GOLDEN AGE OAK VIEW HOME LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 09/28/2023
Certification Date: 09/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 OAK VIEW ST
WAVERLY HALL GA
31831-0459
US

IV. Provider business mailing address

PO BOX 459
WAVERLY HALL GA
31831-0459
US

V. Phone/Fax

Practice location:
  • Phone: 706-582-2117
  • Fax: 706-582-2116
Mailing address:
  • Phone: 706-582-2117
  • Fax: 706-582-2116

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number1-072-1703
License Number StateGA

VIII. Authorized Official

Name: KAYLA JEFFERSON
Title or Position: ADMINISTRATOR
Credential:
Phone: 706-582-2117