Provider Demographics
NPI:1659819175
Name:GOLDEN AGE GUARDIAN CARE
Entity Type:Organization
Organization Name:GOLDEN AGE GUARDIAN CARE
Other - Org Name:LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:TABITHA
Authorized Official - Middle Name:SHIRREL
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-359-2874
Mailing Address - Street 1:144 BUSINESS PARK DR
Mailing Address - Street 2:#203
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462-6527
Mailing Address - Country:US
Mailing Address - Phone:757-463-2969
Mailing Address - Fax:
Practice Address - Street 1:144 BUSINESS PARK DR
Practice Address - Street 2:#203
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462-6527
Practice Address - Country:US
Practice Address - Phone:757-463-2969
Practice Address - Fax:757-222-1229
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-03
Last Update Date:2017-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAHCO-171625251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health