Provider Demographics
NPI:1821585423
Name:A GOLDEN RETREAT CARE HOME, LLC
Entity Type:Organization
Organization Name:A GOLDEN RETREAT CARE HOME, LLC
Other - Org Name:A GOLDEN RETREAT CARE HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:K
Authorized Official - Last Name:STUTSMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-297-4925
Mailing Address - Street 1:8974 W RUTH AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85345-7978
Mailing Address - Country:US
Mailing Address - Phone:623-297-4925
Mailing Address - Fax:623-399-1152
Practice Address - Street 1:18330 W MARCONI AVE
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85388-2358
Practice Address - Country:US
Practice Address - Phone:623-297-4925
Practice Address - Fax:623-399-1152
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-18
Last Update Date:2018-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAL10702H310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility