Healthcare Provider Details

I. General information

NPI: 1730175175
Provider Name (Legal Business Name): GOLDEN AGE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2005
Last Update Date: 01/20/2022
Certification Date: 01/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2901 HIGHWAY 82 E
GREENWOOD MS
38930-6072
US

IV. Provider business mailing address

2901 HWY 82 E
GREENWOOD MS
38930-6072
US

V. Phone/Fax

Practice location:
  • Phone: 662-453-6323
  • Fax: 662-455-9686
Mailing address:
  • Phone: 662-453-6323
  • Fax: 662-455-9686

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number46
License Number StateMS

VIII. Authorized Official

Name: TABATHA WATKINS
Title or Position: ADMINISTRATOR
Credential:
Phone: 662-453-6323