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General NPI Number Information
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NPI Number | 1396960993
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Entity Type | Organization
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Legal Business Name | GOLD STAR ASSISTED LIVING
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Dates
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Enumeration Date | 04/17/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 503 W HIGHWAY 243
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City | CANTON
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State | TX
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Zip | 75103-2113
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Country | US
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Telephone | 903-567-2762
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Fax | 903-567-2237
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Provider Business Mailing Address
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Address Line | PO BOX 1090
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City | CANTON
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State | TX
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Zip | 75103-7090
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Country | US
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Telephone | 903-567-2762
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Fax | 309-567-2237
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Authorized Official
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Title or Position | MANAGER
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Name | MR. JERRY LYNN TIDWELL
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Credential |
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Telephone | 903-567-2762
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number | 030299
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License Number State | TX
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