MEDICARE: GOLDEN COMMUNITY CARE ADULT FAMILY HOME, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	311ZA0620X	Adult Care Home Facility

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1164055091
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GOLDEN COMMUNITY CARE ADULT FAMILY HOME, LLC

Provider Business Mailing Address
First Line	:	12121 E MISSION AVE STE C
Second Line	:
City	:	SPOKANE VALLEY
State	:	WA
Zip	:	99206-4832
Country	:	US
Telephone Number	:	509-443-3102
Fax Number	:

Provider Business Practice Location Address
First Line	:	12121 E MISSION AVE STE C
Second Line	:
City	:	SPOKANE VALLEY
State	:	WA
Zip	:	99206-4832
Country	:	US
Telephone Number	:	509-443-3102
Fax Number	:

Authorized Official
Title or Position	:	OWNER/PROVIDER
Name	:	MAHOULOME HAROLD GUIDI
Credential	:
Telephone Number	:	509-280-7164

Provider Enumeration Date	:	02/19/2020
Last Update Date	:	02/19/2020

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