MEDICARE: GOLDEN MANOR ASSISTED LIVING FACILITY 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	310400000X	Assisted Living 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	:	1396358792
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GOLDEN MANOR ASSISTED LIVING FACILITY LLC

Provider Business Mailing Address
First Line	:	PO BOX 2666
Second Line	:
City	:	LAKE CITY
State	:	FL
Zip	:	32056-2666
Country	:	US
Telephone Number	:	386-697-9425
Fax Number	:

Provider Business Practice Location Address
First Line	:	197 NW GWEN LAKE AVE
Second Line	:
City	:	LAKE CITY
State	:	FL
Zip	:	32055-3711
Country	:	US
Telephone Number	:	386-697-9425
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MARDELL JACKSON
Credential	:
Telephone Number	:	386-697-9425

Provider Enumeration Date	:	08/25/2020
Last Update Date	:	08/25/2020

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