Provider Demographics
NPI:1376007435
Name:GOLDEN GIRLS RESIDENTIAL CARE, LLC
Entity Type:Organization
Organization Name:GOLDEN GIRLS RESIDENTIAL CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:LUCAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:FOWLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-416-9914
Mailing Address - Street 1:214 LARKSPUR LN
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-9600
Mailing Address - Country:US
Mailing Address - Phone:208-413-9914
Mailing Address - Fax:208-798-1833
Practice Address - Street 1:214 LARKSPUR LN
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-9600
Practice Address - Country:US
Practice Address - Phone:208-413-9914
Practice Address - Fax:208-798-1833
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-23
Last Update Date:2019-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)