Healthcare Provider Details

I. General information

NPI: 1356428718
Provider Name (Legal Business Name): GOLDEN AGE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 12/04/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1915 S 18TH ST
CENTERVILLE IA
52544-3102
US

IV. Provider business mailing address

1915 S 18TH ST
CENTERVILLE IA
52544-3102
US

V. Phone/Fax

Practice location:
  • Phone: 641-856-2761
  • Fax: 641-856-2762
Mailing address:
  • Phone: 641-856-2761
  • Fax: 641-856-2762

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number040983
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number040983
License Number StateIA

VIII. Authorized Official

Name: STAN L BIRCHEM
Title or Position: OWNER
Credential:
Phone: 641-856-2757