Provider Demographics
NPI:1790770444
Name:GOLDEN AGE NURSING HOME DISTRICT
Entity Type:Organization
Organization Name:GOLDEN AGE NURSING HOME DISTRICT
Other - Org Name:GOLDEN AGE LIVING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:VERA
Authorized Official - Middle Name:J
Authorized Official - Last Name:CLINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-377-4521
Mailing Address - Street 1:PO BOX 307
Mailing Address - Street 2:
Mailing Address - City:STOVER
Mailing Address - State:MO
Mailing Address - Zip Code:65078-0307
Mailing Address - Country:US
Mailing Address - Phone:573-377-4521
Mailing Address - Fax:573-377-2153
Practice Address - Street 1:404 E 3RD
Practice Address - Street 2:
Practice Address - City:STOVER
Practice Address - State:MO
Practice Address - Zip Code:65078
Practice Address - Country:US
Practice Address - Phone:573-377-4521
Practice Address - Fax:573-377-2153
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-19
Last Update Date:2009-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO031356314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO101487205Medicaid
MO265655Medicare Oscar/Certification