Provider Demographics
NPI:1578560272
Name:GOLDEN AGE HOSPICE, INC
Entity Type:Organization
Organization Name:GOLDEN AGE HOSPICE, INC
Other - Org Name:ALLEVE HOSPICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LATONYA
Authorized Official - Middle Name:FAYE
Authorized Official - Last Name:ROBINSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:405-605-7787
Mailing Address - Street 1:908 S.W. 107TH ST.
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73170-5244
Mailing Address - Country:US
Mailing Address - Phone:405-605-7787
Mailing Address - Fax:405-605-7789
Practice Address - Street 1:908 S.W. 107TH ST.
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73170-5244
Practice Address - Country:US
Practice Address - Phone:405-605-7787
Practice Address - Fax:405-605-7789
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-07
Last Update Date:2010-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4186251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK000371642001OtherBLUE CROSS BLUE SHIELD
OK000371642001OtherBLUE CROSS BLUE SHIELD
=========OtherTRICARE
OK000371642001OtherBLUE CROSS BLUE SHIELD