Healthcare Provider Details

I. General information

NPI: 1598018921
Provider Name (Legal Business Name): GOLDEN AGE SENIOR CARE OF CIELO VISTA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2012
Last Update Date: 10/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7949 SUNMOUNT DR
EL PASO TX
79925-4892
US

IV. Provider business mailing address

125 S WACKER DR STE 1800
CHICAGO IL
60606-4313
US

V. Phone/Fax

Practice location:
  • Phone: 915-772-4036
  • Fax: 915-772-2191
Mailing address:
  • Phone: 312-357-1611
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number133882
License Number StateTX

VIII. Authorized Official

Name: JEFFREY A DAVIS
Title or Position: MANAGING MEMBER
Credential:
Phone: 312-521-7600