Provider Demographics
NPI:1740315118
Name:GOLDEN AGE EXCELL,LLC
Entity type:Organization
Organization Name:GOLDEN AGE EXCELL,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ALEXANDER
Authorized Official - Middle Name:
Authorized Official - Last Name:BRYN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:856-988-9001
Mailing Address - Street 1:14000 SAGEMORE DR
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-3952
Mailing Address - Country:US
Mailing Address - Phone:856-988-9001
Mailing Address - Fax:856-988-9220
Practice Address - Street 1:14000 SAGEMORE DR
Practice Address - Street 2:
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-3952
Practice Address - Country:US
Practice Address - Phone:856-988-9001
Practice Address - Fax:856-988-9220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJQGEVMS261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0048861Medicaid