Provider Demographics
NPI:1174669592
Name:COUNCIL ON AGING GOLDEN AGE CENTER
Entity Type:Organization
Organization Name:COUNCIL ON AGING GOLDEN AGE CENTER
Other - Org Name:GOLDEN AGE CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LOUISE
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-789-2169
Mailing Address - Street 1:155 S 100 W
Mailing Address - Street 2:
Mailing Address - City:VERNAL
Mailing Address - State:UT
Mailing Address - Zip Code:84078-2523
Mailing Address - Country:US
Mailing Address - Phone:435-789-2169
Mailing Address - Fax:435-789-2171
Practice Address - Street 1:155 S 100 W
Practice Address - Street 2:
Practice Address - City:VERNAL
Practice Address - State:UT
Practice Address - Zip Code:84078-2523
Practice Address - Country:US
Practice Address - Phone:435-789-2169
Practice Address - Fax:435-789-2171
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT876000318001Medicaid
CA807028025008Medicaid