NPIMap

Organization Active NPI

Golden Age Inc

Doing business as DME Supplier

  • Durable Medical Equipment & Medical Supplies
  • Greenwood, MS
National Provider Identifier
1730175175
Registry record updated Jan 20, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Durable Medical Equipment & Medical SuppliesTaxonomy code 332B00000X
License
46 Issued in MS
Legal business name
GOLDEN AGE INC
Doing business as
DME Supplier
Practice address
2901 Highway 82 E
Greenwood, MS 38930-6072
Phone
(662) 453-6323
Fax
(662) 455-9686
NPI assigned
Sep 21, 2005
Last updated
Jan 20, 2022By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jan 20, 2022

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Tabatha Watkins
Title
Administrator
Phone
(662) 453-6323

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Durable Medical Equipment & Medical Supplies 332B00000X 46 MS Primary

Addresses

Primary practice location

2901 Highway 82 E
Greenwood, MS 38930-6072

Mailing address

2901 Hwy 82 E
Greenwood, MS 38930-6072
Phone (662) 453-6323

Other identifiers 1

IdentifierTypeStateIssuer
0440264MedicaidMS

Other names 1

  • DME Supplier Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MS

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20100930061803 MS DME Supplier - Nursing Facility Intermediate Care 0941294292 Practice locations: Greenwood, MS

Other NPIs with the same Medicare PAC ID 2

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

National Provider Directory

National Provider Directory
Tax ID family
Golden Age Inc3 organizations share this tax ID, including this one

Other organizations with this tax ID 2

Organizations that report the same tax identification number in the National Provider Directory.

Ownership & related parties

All facility ownership & control disclosures 2

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Golden Age Nursing HomeGreenwood, MS, CCN 255307 Skilled nursing facility 5% Or Greater Direct Ownership Interest (100%) Jul 1, 2004
Golden Age ClinicGreenwood, MS, CCN 253824 Rural health clinic 5% Or Greater Direct Ownership Interest Sep 1, 2010

Owned or controlled facilities with NPI records 2

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

  • Golden Age Inc

    dba Golden Age Clinic

    • Rural Health Clinic/Center
    • Greenwood, MS
    • NPI 1558693671

    5% Or Greater Direct Ownership Interest

    CMS ownership
  • Golden Age Inc
    • Nursing Facility/Intermediate Care Facility
    • Greenwood, MS
    • NPI 1720073448

    5% Or Greater Direct Ownership Interest

    CMS ownership

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1127260800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1642636800000",
    "number": "1730175175",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2901 HWY 82 E",
            "city": "GREENWOOD",
            "state": "MS",
            "postal_code": "389306072",
            "telephone_number": "662-453-6323",
            "fax_number": "662-455-9686"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2901 HIGHWAY 82 E",
            "city": "GREENWOOD",
            "state": "MS",
            "postal_code": "389306072",
            "telephone_number": "662-453-6323",
            "fax_number": "662-455-9686"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "GOLDEN AGE INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2005-09-21",
        "last_updated": "2022-01-20",
        "certification_date": "2022-01-20",
        "status": "A",
        "authorized_official_last_name": "WATKINS",
        "authorized_official_first_name": "TABATHA",
        "authorized_official_title_or_position": "ADMINISTRATOR",
        "authorized_official_telephone_number": "662-453-6323"
    },
    "taxonomies": [
        {
            "code": "332B00000X",
            "taxonomy_group": "",
            "desc": "Durable Medical Equipment & Medical Supplies",
            "state": "MS",
            "license": "46",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "0440264",
            "state": "MS"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "DME Supplier",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "DME Supplier",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Greenwood, MS

Sources for this page

Verify at the official NPI Registry.