Provider Demographics
NPI:1114349263
Name:HEART OF GOLD SENIOR SERVICES
Entity Type:Organization
Organization Name:HEART OF GOLD SENIOR SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:WADE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:863-595-8927
Mailing Address - Street 1:209 FERN RD
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33880-1308
Mailing Address - Country:US
Mailing Address - Phone:863-595-8927
Mailing Address - Fax:863-229-5360
Practice Address - Street 1:209 FERN RD
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33880-1308
Practice Address - Country:US
Practice Address - Phone:863-595-8927
Practice Address - Fax:863-229-5360
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-08
Last Update Date:2014-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL233063251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL009269700Medicaid