MEDICARE: GOLDEN EAGLE

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	208VP0000X	Pain Medicine Physician		CA

General Provider Information

NPI Number	:	1861995987
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GOLDEN EAGLE

Provider Business Mailing Address
First Line	:	14 MONARCH BAY PLZ
Second Line	:
City	:	MONARCH BEACH
State	:	CA
Zip	:	92629-3467
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	14 MONARCH BAY PLZ
Second Line	:
City	:	MONARCH BEACH
State	:	CA
Zip	:	92629-3467
Country	:	US
Telephone Number	:	949-444-3966
Fax Number	:

Authorized Official
Title or Position	:	MEDICAL BILLER
Name	:	ADELLA CORDOVA
Credential	:
Telephone Number	:	623-326-1055

Provider Enumeration Date	:	03/15/2018
Last Update Date	:	03/10/2021

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Directions to “GOLDEN EAGLE ” Practice Location

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