Provider Demographics
NPI:1407172190
Name:GOLDEN AGE ADULT SERVICES. CRP
Entity Type:Organization
Organization Name:GOLDEN AGE ADULT SERVICES. CRP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:MISS
Authorized Official - First Name:GALINA
Authorized Official - Middle Name:
Authorized Official - Last Name:MARKOVICH
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:646-306-7040
Mailing Address - Street 1:21 CANDLE LN
Mailing Address - Street 2:
Mailing Address - City:EAST BRUNSWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08816
Mailing Address - Country:US
Mailing Address - Phone:646-306-7040
Mailing Address - Fax:
Practice Address - Street 1:21 CANDLE LN
Practice Address - Street 2:
Practice Address - City:EAST BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08816
Practice Address - Country:US
Practice Address - Phone:646-306-7040
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-20
Last Update Date:2010-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY476435-1314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYF304085OtherCERTIFICATE