Provider Demographics
NPI:1285140657
Name:GOLDEN AGE HOUSE ASSISTED LIVING LLC
Entity type:Organization
Organization Name:GOLDEN AGE HOUSE ASSISTED LIVING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:GALYNA
Authorized Official - Middle Name:
Authorized Official - Last Name:LONC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-237-2026
Mailing Address - Street 1:31 PORT ECHO LN
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32164-6733
Mailing Address - Country:US
Mailing Address - Phone:386-237-2026
Mailing Address - Fax:
Practice Address - Street 1:102 RAE DR
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32164-6894
Practice Address - Country:US
Practice Address - Phone:386-237-2026
Practice Address - Fax:386-237-2026
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-21
Last Update Date:2017-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility