Provider Demographics
NPI:1396960993
Name:GOLD STAR ASSISTED LIVING
Entity type:Organization
Organization Name:GOLD STAR ASSISTED LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:TIDWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-567-2762
Mailing Address - Street 1:PO BOX 1090
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:TX
Mailing Address - Zip Code:75103-7090
Mailing Address - Country:US
Mailing Address - Phone:903-567-2762
Mailing Address - Fax:309-567-2237
Practice Address - Street 1:503 W HIGHWAY 243
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:TX
Practice Address - Zip Code:75103-2113
Practice Address - Country:US
Practice Address - Phone:903-567-2762
Practice Address - Fax:903-567-2237
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX030299310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility