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General NPI Number Information
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NPI Number | 1558693671
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Entity Type | Organization
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Legal Business Name | GOLDEN AGE INC
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Dates
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Enumeration Date | 02/01/2010
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Last Update Date | 01/06/2022
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Provider Practice Location Address
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Address Line | 2901 HIGHWAY 82 E
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City | GREENWOOD
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State | MS
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Zip | 38930-2960
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Country | US
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Telephone | 662-374-2185
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Fax | 662-374-2195
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Provider Business Mailing Address
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Address Line | 2901 HIGHWAY 82 EAST
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City | GREENWOOD
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State | MS
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Zip | 38930-2960
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Country | US
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Telephone | 662-374-2185
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Fax | 662-374-2195
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | TABATHA DANIELLE WATKINS
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Credential |
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Telephone | 662-453-6323
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QR1300X
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Taxonomy Name | Rural Health Clinic/Center
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License Number |
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License Number State | MS
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