Provider Demographics
NPI:1245386085
Name:GOLDEN AGE SUPERVISORY HOME
Entity Type:Organization
Organization Name:GOLDEN AGE SUPERVISORY HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ROSA
Authorized Official - Middle Name:DIAZ
Authorized Official - Last Name:CAMPOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-466-7885
Mailing Address - Street 1:118 E 11TH STREET
Mailing Address - Street 2:
Mailing Address - City:ELOY
Mailing Address - State:AZ
Mailing Address - Zip Code:85231
Mailing Address - Country:US
Mailing Address - Phone:520-466-7885
Mailing Address - Fax:520-466-7885
Practice Address - Street 1:118 E 11TH STREET
Practice Address - Street 2:
Practice Address - City:ELOY
Practice Address - State:AZ
Practice Address - Zip Code:85231
Practice Address - Country:US
Practice Address - Phone:520-466-7885
Practice Address - Fax:520-466-7885
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ537847Medicaid