MEDICARE: GOLDEN AGE ADULT DAYCARE, 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	261QA0600X	Adult Day Care Clinic/Center

General Provider Information

NPI Number	:	1629312715
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GOLDEN AGE ADULT DAYCARE, LLC

Provider Business Mailing Address
First Line	:	1773 BROADWAY
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11207-1611
Country	:	US
Telephone Number	:	718-576-6336
Fax Number	:

Provider Business Practice Location Address
First Line	:	1773 BROADWAY
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11207-1611
Country	:	US
Telephone Number	:	718-576-6336
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	RUSSEL GLADKOVITSER
Credential	:
Telephone Number	:	718-576-6336

Provider Enumeration Date	:	11/15/2012
Last Update Date	:	11/15/2012

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