Provider Demographics
NPI:1417297425
Name:A GOLDEN LIFE PERSONAL CARE HOME, LLC
Entity Type:Organization
Organization Name:A GOLDEN LIFE PERSONAL CARE HOME, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GENA
Authorized Official - Middle Name:
Authorized Official - Last Name:GOLDEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:877-430-3828
Mailing Address - Street 1:3153 DOVE CT
Mailing Address - Street 2:B
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-3652
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3153 DOVE CT
Practice Address - Street 2:B
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-3652
Practice Address - Country:US
Practice Address - Phone:877-430-3828
Practice Address - Fax:404-220-8856
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-28
Last Update Date:2013-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA504647604OMedicaid
GA507647604JMedicaid
GA504647604KMedicaid
GA507647604EMedicaid
GA504647604LMedicaid
GA507647604BMedicaid
GA507647604HMedicaid
GA507647604FMedicaid
GA507647604GMedicaid
GA507647604IMedicaid
GA507647604CMedicaid
GA504647604MMedicaid
GA507647604NMedicaid