Provider Demographics
NPI:1730823816
Name:GOLDEN ANGEL RESIDENTIAL ASSISTED LIVING
Entity type:Organization
Organization Name:GOLDEN ANGEL RESIDENTIAL ASSISTED LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DUKE
Authorized Official - Middle Name:MUTUA
Authorized Official - Last Name:NYARECHA
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:208-440-6545
Mailing Address - Street 1:2321 N KENMERE DR
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-1675
Mailing Address - Country:US
Mailing Address - Phone:208-440-6545
Mailing Address - Fax:
Practice Address - Street 1:2321 N KENMERE DR
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83646-1675
Practice Address - Country:US
Practice Address - Phone:208-440-6545
Practice Address - Fax:208-376-2908
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-25
Last Update Date:2022-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness