Provider Demographics
NPI:1558753533
Name:GOLDEN LIFE ASSISTED LIVING HOME-1
Entity Type:Organization
Organization Name:GOLDEN LIFE ASSISTED LIVING HOME-1
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:
Authorized Official - Last Name:SIDDIQUI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-332-0780
Mailing Address - Street 1:4113 W HAYWARD AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85051-5751
Mailing Address - Country:US
Mailing Address - Phone:602-332-0780
Mailing Address - Fax:623-399-8915
Practice Address - Street 1:4113 W HAYWARD AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85051-5751
Practice Address - Country:US
Practice Address - Phone:602-332-0780
Practice Address - Fax:623-399-8915
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-27
Last Update Date:2015-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAL8880H311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ926240Medicaid