Provider Demographics
NPI:1396358792
Name:GOLDEN MANOR ASSISTED LIVING FACILITY LLC
Entity Type:Organization
Organization Name:GOLDEN MANOR ASSISTED LIVING FACILITY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARDELL
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-697-9425
Mailing Address - Street 1:PO BOX 2666
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32056-2666
Mailing Address - Country:US
Mailing Address - Phone:386-697-9425
Mailing Address - Fax:
Practice Address - Street 1:197 NW GWEN LAKE AVE
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32055-3711
Practice Address - Country:US
Practice Address - Phone:386-697-9425
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-25
Last Update Date:2020-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility