Provider Demographics
NPI:1740504984
Name:GOLDEN TRIANGLE LIVING CENTER
Entity type:Organization
Organization Name:GOLDEN TRIANGLE LIVING CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:E
Authorized Official - Last Name:RICHARDSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-445-6470
Mailing Address - Street 1:2750 S 4TH ST
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77701-7912
Mailing Address - Country:US
Mailing Address - Phone:409-832-4112
Mailing Address - Fax:318-641-3717
Practice Address - Street 1:101 OGLESBEE RD
Practice Address - Street 2:
Practice Address - City:SILSBEE
Practice Address - State:TX
Practice Address - Zip Code:77656-5925
Practice Address - Country:US
Practice Address - Phone:409-385-5807
Practice Address - Fax:318-641-3717
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-17
Last Update Date:2010-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0000I8H4SMedicaid