Healthcare Provider Details

I. General information

NPI: 1376007435
Provider Name (Legal Business Name): GOLDEN GIRLS RESIDENTIAL CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2019
Last Update Date: 04/14/2025
Certification Date: 04/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

214 LARKSPUR LN
LEWISTON ID
83501-9600
US

IV. Provider business mailing address

214 LARKSPUR LN
LEWISTON ID
83501-9600
US

V. Phone/Fax

Practice location:
  • Phone: 208-413-9914
  • Fax: 208-798-1833
Mailing address:
  • Phone: 208-413-9914
  • Fax: 208-798-1833

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code311500000X
TaxonomyAlzheimer Center (Dementia Center)
License Number
License Number State

VIII. Authorized Official

Name: MR. LUCAS J FOWLER
Title or Position: PRESIDENT/EXECUTIVE DIRECTOR
Credential:
Phone: 208-416-9914