Provider Demographics
NPI:1700085453
Name:GOLDEN AGE FOOTCARE INC
Entity Type:Organization
Organization Name:GOLDEN AGE FOOTCARE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BOREMY
Authorized Official - Middle Name:
Authorized Official - Last Name:LY
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:816-304-8452
Mailing Address - Street 1:7818 N HULL AVE
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64151-1532
Mailing Address - Country:US
Mailing Address - Phone:816-304-8452
Mailing Address - Fax:
Practice Address - Street 1:7818 N HULL AVE
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64151-1532
Practice Address - Country:US
Practice Address - Phone:816-304-8452
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-13
Last Update Date:2011-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Single Specialty