Provider Demographics
NPI:1518998020
Name:GOLDEN AGE SENIOR CARE HOSPITAL, LLC
Entity Type:Organization
Organization Name:GOLDEN AGE SENIOR CARE HOSPITAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:O
Authorized Official - Last Name:BIGBY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-651-0920
Mailing Address - Street 1:PO BOX 6
Mailing Address - Street 2:
Mailing Address - City:BASTROP
Mailing Address - State:LA
Mailing Address - Zip Code:71221-0006
Mailing Address - Country:US
Mailing Address - Phone:318-556-8000
Mailing Address - Fax:318-556-1197
Practice Address - Street 1:4310 S GRAND ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71202-6322
Practice Address - Country:US
Practice Address - Phone:318-651-0920
Practice Address - Fax:318-651-0921
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2009-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA540283Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1709531Medicaid
LA190061362ZOtherBCBS OF LOUISIANA
LA1709531Medicaid