=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396390811
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GOLDEN GROUP HOME SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/02/2019
-----------------------------------------------------
Last Update Date | 05/31/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 28 STATE ST STE 4
-----------------------------------------------------
City | GORHAM
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04038-1147
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-415-5393
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 28 STATE ST STE 4
-----------------------------------------------------
City | GORHAM
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04038-1147
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-415-5393
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF EXECUTIVE OFFICER
-----------------------------------------------------
Name | MR. MICHEL KANYAMBO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 207-415-5393
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320900000X
-----------------------------------------------------
Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------