MEDICARE: GOLDEN AGE SENIOR CARE HOSPITAL, 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	283Q00000X	Psychiatric Hospital	540	LA

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
2	190061362Z	OTHER	LA	BCBS OF LOUISIANA

General Provider Information

NPI Number	:	1518998020
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GOLDEN AGE SENIOR CARE HOSPITAL, LLC

Provider Business Mailing Address
First Line	:	PO BOX 6
Second Line	:
City	:	BASTROP
State	:	LA
Zip	:	71221-0006
Country	:	US
Telephone Number	:	318-556-8000
Fax Number	:	318-556-1197

Provider Business Practice Location Address
First Line	:	4310 S GRAND ST
Second Line	:
City	:	MONROE
State	:	LA
Zip	:	71202-6322
Country	:	US
Telephone Number	:	318-651-0920
Fax Number	:	318-651-0921

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	WALTER O BIGBY
Credential	:
Telephone Number	:	318-651-0920

Provider Enumeration Date	:	07/05/2006
Last Update Date	:	03/11/2009

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