Provider Demographics
NPI:1417462185
Name:GOLDEN GATE MANOR INC
Entity Type:Organization
Organization Name:GOLDEN GATE MANOR INC
Other - Org Name:GOLDEN GATE MANOR 2
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRIMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-369-6290
Mailing Address - Street 1:1337 W ABRIENDO AVE
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81004-1005
Mailing Address - Country:US
Mailing Address - Phone:719-369-6290
Mailing Address - Fax:
Practice Address - Street 1:1219 LAKE AVE
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81004-2845
Practice Address - Country:US
Practice Address - Phone:719-369-6290
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-04
Last Update Date:2017-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO230654310400000X, 385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No385H00000XRespite Care FacilityRespite Care