Provider Demographics
NPI:1316410764
Name:GOLDEN CARE SUPPORTED LIVING
Entity Type:Organization
Organization Name:GOLDEN CARE SUPPORTED LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MOHAMED
Authorized Official - Middle Name:
Authorized Official - Last Name:FOFANAH
Authorized Official - Suffix:
Authorized Official - Credentials:MPH
Authorized Official - Phone:614-929-1931
Mailing Address - Street 1:5530 99TH ST APT 3K
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:NY
Mailing Address - Zip Code:11368-3735
Mailing Address - Country:US
Mailing Address - Phone:347-579-6274
Mailing Address - Fax:
Practice Address - Street 1:5530 99TH ST APT 3K
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:NY
Practice Address - Zip Code:11368-3735
Practice Address - Country:US
Practice Address - Phone:347-579-6274
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-08
Last Update Date:2019-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health