Provider Demographics
NPI:1831312339
Name:GOLDEN GATE MANOR
Entity Type:Organization
Organization Name:GOLDEN GATE MANOR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:HARRIMAN
Authorized Official - Suffix:I
Authorized Official - Credentials:LIC PSY TECH-MENTALL
Authorized Official - Phone:719-564-0344
Mailing Address - Street 1:606 W ABRIENDO AVE
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81004-1545
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:606 W ABRIENDO AVE
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81004-1545
Practice Address - Country:US
Practice Address - Phone:719-583-9132
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-11
Last Update Date:2008-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAL0183310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility