Healthcare Provider Details

I. General information

NPI: 1043208796
Provider Name (Legal Business Name): GOLDEN AGE NURSING HOME DISTRICT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2005
Last Update Date: 11/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12498 SE HIGHWAY 116
BRAYMER MO
64624-9107
US

IV. Provider business mailing address

12498 SE HIGHWAY 116
BRAYMER MO
64624-9107
US

V. Phone/Fax

Practice location:
  • Phone: 660-645-2243
  • Fax: 660-645-2719
Mailing address:
  • Phone: 660-645-2243
  • Fax: 660-645-2719

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number038984
License Number StateMO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier101487106
Identifier TypeMEDICAID
Identifier StateMO
Identifier Issuer

VIII. Authorized Official

Name: MS. TAMMY J MURDOCK
Title or Position: ADMINISTRATOR
Credential: LPN
Phone: 660-645-2243