Provider Demographics
NPI:1598018921
Name:GOLDEN AGE SENIOR CARE OF CIELO VISTA, LLC
Entity Type:Organization
Organization Name:GOLDEN AGE SENIOR CARE OF CIELO VISTA, LLC
Other - Org Name:SUNRIDGE AT CIELO VISTA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:A
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-521-7600
Mailing Address - Street 1:125 S WACKER DR STE 1800
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60606-4313
Mailing Address - Country:US
Mailing Address - Phone:312-357-1611
Mailing Address - Fax:
Practice Address - Street 1:7949 SUNMOUNT DR
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79925-4892
Practice Address - Country:US
Practice Address - Phone:915-772-4036
Practice Address - Fax:915-772-2191
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-23
Last Update Date:2012-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX133882310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility