MEDICARE: GOLDEN LAKE CARE HOME

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	7557-AGC-7	NV

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	:	1568968733
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GOLDEN LAKE CARE HOME

Provider Business Mailing Address
First Line	:	9719 TUMBLE LAKE CT
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89147-6749
Country	:	US
Telephone Number	:	702-755-1800
Fax Number	:

Provider Business Practice Location Address
First Line	:	9719 TUMBLE LAKE CT
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89147-6749
Country	:	US
Telephone Number	:	702-755-1800
Fax Number	:

Authorized Official
Title or Position	:	EMPLOYEE/AGENT
Name	:	SOKHENA K HUCH
Credential	:
Telephone Number	:	702-755-1800

Provider Enumeration Date	:	04/04/2018
Last Update Date	:	04/04/2018

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Directions to “GOLDEN LAKE CARE HOME ” Practice Location

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