Basic Information
| Provider Information | |||||||||
| NPI: | 1487604138 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GGNSC TOMAHAWK GOLDEN AGE LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | GOLDEN LIVINGCENTER - GOLDEN AGE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 720 E KING RD | ||||||||
| Address2: | |||||||||
| City: | TOMAHAWK | ||||||||
| State: | WI | ||||||||
| PostalCode: | 544871513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7154532164 | ||||||||
| FaxNumber: | 7154531066 | ||||||||
| Practice Location | |||||||||
| Address1: | 720 E KING RD | ||||||||
| Address2: | |||||||||
| City: | TOMAHAWK | ||||||||
| State: | WI | ||||||||
| PostalCode: | 544871513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7154532164 | ||||||||
| FaxNumber: | 7154531066 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2006 | ||||||||
| LastUpdateDate: | 07/17/2014 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RASMUSSEN-JONES | ||||||||
| AuthorizedOfficialFirstName: | HOLLY | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 4792014835 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 2733 | WI | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 20196600 | 05 | WI | MEDICAID | 7122719 | 01 | WI | MEDICA SELECTCARE | OTHER | 7122719 | 01 | WI | MEDICA CHOICE | OTHER | 525334 | 01 | WI | SECURITY HEALTH PLAN | OTHER |