Basic Information
| Provider Information | |||||||||
| NPI: | 1083043780 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GOLDEN AGE OPERATIONS, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | GOLDEN AGE - INMAN | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 82 NORTH MAIN STREET | ||||||||
| Address2: | |||||||||
| City: | INMAN | ||||||||
| State: | SC | ||||||||
| PostalCode: | 293491602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8644726636 | ||||||||
| FaxNumber: | 8644726524 | ||||||||
| Practice Location | |||||||||
| Address1: | 82 NORTH MAIN STREET | ||||||||
| Address2: | |||||||||
| City: | INMAN | ||||||||
| State: | SC | ||||||||
| PostalCode: | 293491602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8644726636 | ||||||||
| FaxNumber: | 8644726524 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2013 | ||||||||
| LastUpdateDate: | 05/07/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | TIMOTHY | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | LEAD ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 8644726636 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.