Provider Demographics
NPI:1194717520
Name:GOLDEN STATE MEDICAL INC
Entity type:Organization
Organization Name:GOLDEN STATE MEDICAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAVES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-696-2900
Mailing Address - Street 1:PO BOX 300
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:CA
Mailing Address - Zip Code:95604-0300
Mailing Address - Country:US
Mailing Address - Phone:800-696-2900
Mailing Address - Fax:530-885-3631
Practice Address - Street 1:200 LINDEN AVE
Practice Address - Street 2:100
Practice Address - City:AUBURN
Practice Address - State:CA
Practice Address - Zip Code:95603-5280
Practice Address - Country:US
Practice Address - Phone:800-696-2900
Practice Address - Fax:530-885-3631
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-22
Last Update Date:2021-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
CACO2725335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADME01705FMedicaid
CADME01705FMedicaid