Provider Demographics
NPI:1558693671
Name:GOLDEN AGE INC
Entity Type:Organization
Organization Name:GOLDEN AGE INC
Other - Org Name:GOLDEN AGE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TABATHA
Authorized Official - Middle Name:DANIELLE
Authorized Official - Last Name:WATKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-453-6323
Mailing Address - Street 1:2901 HIGHWAY 82 EAST
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:38930-2960
Mailing Address - Country:US
Mailing Address - Phone:662-374-2185
Mailing Address - Fax:662-374-2195
Practice Address - Street 1:2901 HIGHWAY 82 E
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:MS
Practice Address - Zip Code:38930-2960
Practice Address - Country:US
Practice Address - Phone:662-374-2185
Practice Address - Fax:662-374-2195
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-01
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X
MS261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09705072Medicaid
MS253824Medicare Oscar/Certification