Provider Demographics
NPI:1164055091
Name:GOLDEN COMMUNITY CARE ADULT FAMILY HOME, LLC
Entity Type:Organization
Organization Name:GOLDEN COMMUNITY CARE ADULT FAMILY HOME, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:MAHOULOME
Authorized Official - Middle Name:HAROLD
Authorized Official - Last Name:GUIDI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-280-7164
Mailing Address - Street 1:12121 E MISSION AVE STE C
Mailing Address - Street 2:
Mailing Address - City:SPOKANE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:99206-4832
Mailing Address - Country:US
Mailing Address - Phone:509-443-3102
Mailing Address - Fax:
Practice Address - Street 1:12121 E MISSION AVE STE C
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99206-4832
Practice Address - Country:US
Practice Address - Phone:509-443-3102
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-19
Last Update Date:2020-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA752707Medicaid