Healthcare Provider Details

I. General information

NPI: 1336816222
Provider Name (Legal Business Name): GOLDEN RIDGE ASSITED LIVING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2021
Last Update Date: 08/27/2021
Certification Date: 08/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 MONTANA AVE
LEAD SD
57754-1051
US

IV. Provider business mailing address

200 MONTANA AVE
LEAD SD
57754-1051
US

V. Phone/Fax

Practice location:
  • Phone: 605-639-0115
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number State

VIII. Authorized Official

Name: ROBERT BAGDON
Title or Position: COO
Credential:
Phone: 724-961-6061