Provider Demographics
NPI:1235290768
Name:FAMILY/GOLDEN AGE CARE LLC
Entity Type:Organization
Organization Name:FAMILY/GOLDEN AGE CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:GLORIA
Authorized Official - Middle Name:NKECHI
Authorized Official - Last Name:MBANU
Authorized Official - Suffix:
Authorized Official - Credentials:REGISTERED NURSING
Authorized Official - Phone:219-980-1839
Mailing Address - Street 1:7325 BELL STREET
Mailing Address - Street 2:
Mailing Address - City:SCHERERVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46375-3524
Mailing Address - Country:US
Mailing Address - Phone:219-980-1839
Mailing Address - Fax:219-322-7210
Practice Address - Street 1:7325 BELL STREET
Practice Address - Street 2:
Practice Address - City:SCHERERVILLE
Practice Address - State:IN
Practice Address - Zip Code:46375-3524
Practice Address - Country:US
Practice Address - Phone:219-980-1839
Practice Address - Fax:219-322-7210
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-12
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200501790OtherMEDICAID WAIVER