Provider Demographics
NPI:1730175175
Name:GOLDEN AGE INC
Entity type:Organization
Organization Name:GOLDEN AGE INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TABATHA
Authorized Official - Middle Name:
Authorized Official - Last Name:WATKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-453-6323
Mailing Address - Street 1:2901 HWY 82 E
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:38930-6072
Mailing Address - Country:US
Mailing Address - Phone:662-453-6323
Mailing Address - Fax:662-455-9686
Practice Address - Street 1:2901 HIGHWAY 82 E
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:MS
Practice Address - Zip Code:38930-6072
Practice Address - Country:US
Practice Address - Phone:662-453-6323
Practice Address - Fax:662-455-9686
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-21
Last Update Date:2022-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS46332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0440264Medicaid
MS0440264Medicaid