MEDICARE: GOLDEN AGE HOSPICE, INC

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	251G00000X	Community Based Hospice Care Agency	4186	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000371642001	OTHER	OK	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1578560272
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GOLDEN AGE HOSPICE, INC

Provider Business Mailing Address
First Line	:	908 S.W. 107TH ST.
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73170-5244
Country	:	US
Telephone Number	:	405-605-7787
Fax Number	:	405-605-7789

Provider Business Practice Location Address
First Line	:	908 S.W. 107TH ST.
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73170-5244
Country	:	US
Telephone Number	:	405-605-7787
Fax Number	:	405-605-7789

Authorized Official
Title or Position	:	PRESIDENT/ADMINISTRATOR
Name	:	MRS. LATONYA FAYE ROBINSON
Credential	:	LCSW
Telephone Number	:	405-605-7787

Provider Enumeration Date	:	07/07/2005
Last Update Date	:	11/23/2010

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