Basic Information
| Provider Information | |||||||||
| NPI: | 1407372329 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GOLDEN AGE SENIOR CARE OF DESERT SPRINGS, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SUNRIDGE AT DESERT SPRINGS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5555 W GRANDE MARKET DR STE A | ||||||||
| Address2: | |||||||||
| City: | APPLETON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549138403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9205743833 | ||||||||
| FaxNumber: | 9205743850 | ||||||||
| Practice Location | |||||||||
| Address1: | 5901 BANDOLERO DR | ||||||||
| Address2: | |||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799126662 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9158420900 | ||||||||
| FaxNumber: | 9158420903 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2017 | ||||||||
| LastUpdateDate: | 03/03/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| AuthorizedOfficialLastName: | DAVIS | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 3125217600 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 03/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 311500000X | N | Nursing & Custodial Care Facilities | Alzheimer Center (Dementia Center) | 310400000X | 144733 | TX | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
No ID Information.