Healthcare Provider Details

I. General information

NPI: 1740449834
Provider Name (Legal Business Name): GOLDEN AGE GARDEN NURSING HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/04/2008
Last Update Date: 06/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HC 67 BOX 15513
FAJARDO PR
00738-9705
US

IV. Provider business mailing address

HC 67 BOX 15513
FAJARDO PR
00738-9705
US

V. Phone/Fax

Practice location:
  • Phone: 787-613-9827
  • Fax:
Mailing address:
  • Phone: 787-613-9827
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License Number31904
License Number StatePR

VIII. Authorized Official

Name: MR. OMAR ROSA LOPEZ
Title or Position: SUPERVISOR
Credential: RN BSN 31904
Phone: 787-860-6835