Provider Demographics
NPI:1639442726
Name:GOLDEN TRIANGLE GERIATRIC COLLABORATIVE, LLC
Entity Type:Organization
Organization Name:GOLDEN TRIANGLE GERIATRIC COLLABORATIVE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:ATKINSON
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:662-320-4008
Mailing Address - Street 1:100 WILBURN WAY
Mailing Address - Street 2:
Mailing Address - City:STARKVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39759-3692
Mailing Address - Country:US
Mailing Address - Phone:662-320-4008
Mailing Address - Fax:662-323-6007
Practice Address - Street 1:100 WILBURN WAY
Practice Address - Street 2:
Practice Address - City:STARKVILLE
Practice Address - State:MS
Practice Address - Zip Code:39759-3692
Practice Address - Country:US
Practice Address - Phone:662-320-4008
Practice Address - Fax:662-323-6007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-20
Last Update Date:2012-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR850904364SG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes364SG0600XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistGerontologyGroup - Single Specialty